Background/Purpose: Glucocorticoid induced osteoporosis (GIOP) is an under-recognized and under-treated condition. Many long-term glucocorticoid (GC) users never receive therapy to prevent bone loss or are only treated after a fracture occurs, despite having known risk factors and available effective therapies to prevent fracture. Our quality improvement study measures 1) osteoporosis (OP) screening rates, and 2) adherence to 2017 ACR guidelines for prevention and treatment of GIOP in the rheumatoid arthritis (RA) patient population at our tertiary care academic rheumatology practice.

Methods: A retrospective review of RA patients (ICD codes M05 and M06) over age of 50 yrs and on long-term GC (≥3 months) from 1/1/2015 through 12/31/2017 was performed. The following variables were recorded and validated manually: demographics (age/sex/ethnicity/height/weight), smoking status, GC dose and duration (excluding non-oral formulations and oral tapers), DEXA scans, and left femoral neck T-score (LFNTS). OP screening rates with DEXA scans were measured. A FRAX score was calculated using the online University of Sheffield FRAX calculator. The FRAX score for major osteoporotic fracture risk and hip fracture risk was increased by 15% and 20% respectively for high dose GC use (>7.5mg/day) per ACR guideline recommendations. Patients were risk-stratified as high (LFNTS ≤-2.5, or FRAX 10 yr risk of major and hip OP fracture of ≥20% and ≥3% respectively) , moderate (FRAX 10 yr risk of major and hip OP fracture of 10-20% and 1-3% respectively) or low risk (FRAX 10 yr risk of major and hip OP fracture of <10% and <1% respectively). We measured the percentage of patients in each category on appropriate OP treatment (defined for high and moderate risk categories as bisphosphonates, and for low risk as calcium/vit D supplementation and/or bisphosphonates).

Results: We identified 1,746 patients with RA over age of 50 yrs during the 3 year study period. Of these, 127 patients were on long term GC (≥3 months). Mean age was 65 yrs, 79% were female, 88% were Caucasian, and 54% were current smokers, mean GC dose was 6.5mg/day (prednisone equivalent), and 28% were on high dose GC (>7.5mg/day). Appropriate DEXA screening was performed in 80 (63%) patients. The OP fracture risk stratification of these 80 patients was as follows: 43, 23, and 14 patients were in the high, moderate, and low risk category respectively. The percentage on appropriate treatment in the high, moderate, and low risk categories were 44%, 52%, and 86% (low risk breakdown = 9 calcium/vit D supplementation and 3 bisphosphonates) respectively. Multivariate analysis of predictive risk factors for non-adherence to screening and treatment is ongoing.

Conclusion: In our study on GIOP screening and treatment in RA patients on long term GC therapy, 63% received appropriate OP screening, whereas 44% of the high fracture risk patients and 52% of the moderate risk patients were found to be on appropriate GIOP treatment. A multi-faceted QI initiative to improve GIOP management is underway at our institution- creation of an EHR best practice alert and EHR FRAX calculator along with continued medical education and shared performance metrics. We plan to measure performance closely over time post-intervention.

« Back to 2018 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/adherence-to-guideline-recommendations-for-screening-and-treatment-of-glucocorticoid-induced-osteoporosis-in-patients-with-rheumatoid-arthritis-on-long-term-glucocorticoid-therapy-at-a-tertiary-care-c/