Background/Purpose: Glucocorticosteroid-induced osteoporosis (GIO) is the most common cause of secondary osteoporosis but is under-diagnosed and under-treated.  Most professional guidelines recommend as a first step calcium and vitamin D (Ca/VitD) supplementation for patients treated with prednisone ≥ 5-7.5 mg daily or equivalent for ≥ 1-3 months.

Rheumatology inpatient consultations are routinely given by our rheumatology unit with emphasis on smooth transition to outpatient care.  The study objectives were to examine the real-life implementation of recommendations for Ca/VitD supplementation in patients anticipated to receive long-term corticosteroid treatment and to assess the impact of standardized academic lecture on guideline implementation.

Methods: All rheumatology inpatient consultations given in 4 internal medicine wards in an academic community-based hospital in 2018 were included in the study.  The hospital inpatient database was queried by two independent rheumatologists regarding the total number and content of rheumatology consult notes, doses and indications for steroid treatment where applicable, diagnostic codes, and discharge medications including Ca/VitD for patients prescribed ≥ 7.5 mg/day of prednisone with anticipated treatment for ≥ 1 month.  Patients who died during hospitalization and patients hospitalized with diagnostic code of sarcoidosis were excluded from this analysis.    

During the month of July 2018, standardized academic lectures on GIO prevention were given by rheumatologists in 3 of the 4 internal medicine wards.  The fourth internal medicine ward served as control.  The percentage of patients for whom Ca/VitD was both recommended and prescribed and the impact of academic lecture on discharge prescriptions was calculated and compared between the 6-month period before and after the instructional intervention and to the corresponding data in the control internal medicine ward.   Variables were compared by Chi Square test or Student’s t-test, as appropriate.  All tests were 2-sided; p < 0.05 was considered statistically significant.

Results: Rheumatology consultations were given to 559 inpatients in 2018, 101 of whom had steroid treatment and should have been treated with Ca/VitD. The mean age of the patients was 64.6±16.1 years, 59.4% female. The main rheumatologic indications for corticosteroid treatment were vasculitis (26.7%), connective tissue disease (22.8%), rheumatoid arthritis (18.8%), and crystal-induced arthropathy (14.9%). In 79.2% of cases, rheumatology consultations specifically recommended Ca/VitD, but only 44.3% of patients were discharged on supplementation. No statistically significant differences were found among the four wards. GIO prevention lecture had no impact on discharge prescriptions. 

Conclusion: Real-life implementation of GIO prevention guidelines is poor in internal medicine wards.   A collaborative learning program not limited only to academic lectures is recommended as measure of intervention to increase GIO awareness and prevention especially among internal medicine staff.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/implementation-of-recommendations-for-prevention-of-glucocorticosteroid-induced-osteoporosis-in-hospitalized-patients/