Background/Purpose:  Therapeutic glucocorticoids (GC) rapidly decrease bone mineral density, inducing a remodelling imbalance by promoting osteoclast differentiation and activation and by inhibiting oscteocytes. Current guidelines direct that bisphosphonates (BP’s) and elemental calcium (Ca⁺⁺) with Vitamin D (Vit. D) should be given at initiation of GC therapy, as it is known that bone remodelling imbalance occurs early with steroid usage. We circulated these guidelines within our hospital after auditing the existing practice of the hospitals doctors and 1yr later we sought to measure the efficacy of our intervention by completing an audit loop.

Methods: A cross sectional audit was performed of all adult medical and surgical inpatients in a tertiary referral centre teaching hospital. Prescribed GC and  concurrent anti osteoporotic medication were noted. Subsequent to the initial audit, guidelines promoting the use of BP’s, Ca⁺⁺ and Vit. D when prescribing GC’s were advertised on hospital notice boards, in hospital bulletins, hospital prescribing guidelines and on the hospital website. One year after promoting guidelines the audit loop was completed by performing a similar cross sectional audit.

Results:

All inpatient medical records (n=417) were reviewed in Jan 2010.  52% of the inpatients were female and 58% were older than 65. 66/417 (16%) inpatients had been prescribed GC’s. Ca⁺⁺ with Vit. D was prescribed for 20% of patients on GC’s with 2% also receiving BP therapy. 3% of patients were also receiving-post menopausal hormone replacement therapy.

In Nov 2011 one year after guideline publication, all 452 inpatient medical records (n=452) were reviewed.  63% of the patients were female and 60% were older than 65. 55/452 (12%) inpatients were prescribed GC’s. Ca⁺⁺ with Vit. D was prescribed for 55% of patients on systemic steroids with 20% also receiving BP therapy.

The resultant improvement in the co-prescription of Ca⁺⁺ & Vit. D and BP’s with GC’s by the order of 2.35 and 10 respectively can be attributed in part to the circulation of hospital guidelines. However 45% of patients on systemic steroids continued to receive no bone protection and 80% received suboptimal bone protection from steroid induced osteoporosis.  

Conclusion: Publication and advertisement of current bone protection guidelines when prescribing systemic steroids resulted in a substantial but suboptimal improvement by hospital doctors in our hospital in the co-prescription of bone protecting drugs to prevent steroid induced osteoporosis. In this audit it appears that the majority of prescribers do recognise the necessity to protect bone health when a patient requires steroids. However a substantial number of patients did not receive any bone protection. It is our perception that many physicians are not aware that short courses of steroids reduce bone mineral density and therefore greater efforts must be made to enhance doctor awareness of the necessity for bone protection to be prescribed at initiation of systemic steroids.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-efficacy-of-clinical-guidelines-in-promoting-co-prescription-of-bone-protection-with-glucocorticoids-among-hospital-doctors-treating-inpatients/