SAN DIEGO – Physicians overall are doing a less than stellar job of recognizing glucocorticoid-induced osteoporosis and prescribing bone-protective medications for affected or high-risk patients.
But some specialties are doing significantly better than others.
“While many rheumatologists and endocrinologists are doing a pretty good job, we know that collectively, internationally, this still continues to be a major therapeutic dilemma, and steroids still constitute the most common form of drug-induced osteoporosis,” said Dr. Kenneth G. Saag.
He cited a recent as-yet-unpublished study led by University of Alabama epidemiologist Ryan C. Outman, who, together with his coinvestigators, analyzed 106,310 patients in the Medco Pharmacy database who were at high risk for glucocorticoid-induced osteoporosis (GIOP) by virtue of having received more than 90 days of systemic corticosteroid therapy during the study years of 2004-2007.
The primary study outcome was prescription of any form of anti-GIOP medication within 12 months after patients reached the 90-day mark of steroid therapy. The 12-month mark is the point on the therapeutic time line when, according to American College of Rheumatology guidelines, physicians are supposed to initiate bone-protective therapy.
The steroids were prescribed by a total of 53,766 physicians. During the 12-month window, the physicians ordered bone mineral density tests in just 4.6% of the patients, and 23.5% of patients received a prescription for an anti-GIOP medication, according to Dr. Saag, professor of medicine and epidemiology at the University of Alabama, Birmingham.
The results varied by physician specialty. In a multivariate analysis adjusted for patient age, gender, and other potential confounders, endocrinologists were 61% more likely to prescribe anti-GIOP medication for patients having more than 90 days of exposure to systemic steroids than were internists, who served as the reference standard. Rheumatologists were 59% more likely than internists to prescribe therapy.
Nephrologists, pulmonologists, and gastroenterologists were 37%, 34%, and 15%, respectively, more likely to have prescribed bone-protective medications for their at-risk patients than were internists.
Dermatologists and physicians in all other specialties who prescribed steroids for longer than 90 days were, collectively, 22% less likely to introduce anti-GIOP therapy than were internists.
Rates of prescription of anti-GIOP medications were particularly low in men of all ages and in premenopausal women. During the 12 months after more than 90 days of exposure to systemic steroids, 36.8% of affected women aged 50 years or older were prescribed bone-protective medication, compared with 11.4% of affected women under age 50 years and 14.7% of men of any age, said Dr. Saag, who was not involved in the study.
“We've got a lot of work to do in terms of initiating therapy, but adherence is a big problem, too. Less than half of patients who start on any bone-protective drug are still taking it a year later,” he said.
Dr. Saag disclosed that he has received research grants from and serves as a paid consultant to Amgen, Eli Lilly, Merck, and Novartis.