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A. Bankole, S. Pachigolla
Published: 19 May 2021
 by  BMJ

Abstract: Background: Glucocorticoids (GC) are used in the treatment of various inflammatory conditions and it is estimated that about 1% of US population is treated with long term steroids. High doses of GC particularly those used by rheumatologists have adverse effects on bone health and is associated with rapid bone loss resulting in Glucocorticoid induced Osteoporosis(GIO) and an increased risk of fractures. The risk of bone loss relates to high daily dose and the high cumulative dose of the GC. Despite the availability of effective preventative and treatment options, GIO is often under treated with many patients treated only after a fracture has occurred. Objectives: The purpose of this study was to examine if providing education to care providers lead to an improvement in the identification, evaluation, and treatment of GIO. Methods: This is a single center, prospective study that was performed at a university based tertiary referral center. Patients over 40 years, receiving a total cumulative dose of GC of >5 grams and/or a single dose of >30 mg of prednisone or equivalent was enrolled. A patient list was generated by our technology group. All providers received intervention in the form of an academic Journal Club, at which the current ACR guidelines regarding GIO was reviewed. Monthly reminders were shared with all providers within our monthly communications. All the pre and post interventional data was analyzed. The continuous variables were analyzed using T-test or Mann-Whitney U test. Categorical variables were analyzed using Chi-square Tests or Fisher’s exact tests. Statistical analysis was performed using SAS9.4, and p value <0.05 was considered statistically significant. Results: Post education, there was a statistically significant increase in vitamin D replacement and the use of bisphosphonates as well as a reduction in the use of bone mineral density (BMD) tests within the at risk group while on GC. Table 1. Glucocorticoid induced Osteoporosis (GIO) Pre-treatment(N=72) Post-treatment(N=54) p-value Demographics Age (years) 58.9 ± 19.2 64.2 ± 16.7 0.11 Body Mass Index 29.0 ± 6.7 29.4 ± 8.4 0.77 Gender (Female) 73.6% 74.1% 0.95 Race White 83.3% 77.8% 0.43 Hispanic 1.4% 5.6% 0.31 Insurance ANTHEM BCBS 16.9% 26.9% Commercial 11.3% 11.5% Medicaid 12.7% 9.6% Medicare 59.2% 51.9% 0.58 Medical History Osteoporosis 68.1% 64.8% 0.70 Osteoporotic Fracture 15.3% 11.1% 0.50 Vasculitis 26.4% 22.2% 0.59 Systemic Lupus Erythematosus 18.1% 13.0% 0.44 Rheumatoid Arthritis 12.5% 25.9% 0.05 Polymyalgia Rheumatica 6.9% 11.1% 0.41 Inflammatory Muscle Disease 18.1% 20.4% 0.74 Spondyloarthritis 1.4% 1.9% 0.99 Lab Results Serum Vitamin D (Normal) 41.3% (19/46) 52.8% (19/36) 0.3 GIO Prevention Measures Calcium 2.8% 13.0% 0.04 Vitamin D 18.1% 61.1% <0.01 Bisphosphonates 9.7% 35.2% <0.01 RANKL inhibitors 4.2% 11.1% 0.17 Bone Mineral Density 43.5% (10/23) 10.5% (2/19) 0.02 Conclusion: There was a significant improvement between the GIO pre and post-educational data, with increasing use of GIO preventive measures. Importantly, there was also a reduction in BMD testing of patients while still on GC. This research show the importance of provider education as a means of disseminating information and improving the quality of patient care. References: [1]Compston J. Glucocorticoid-induced osteoporosis: an update. Endocrine. 2018 Jul;61(1):7-16. doi: 10.1007/s12020-018-1588-2. [2]2017 American college of rheumatology guideline for the prevention and treatment of Glucocorticoid-induced Osteoporosis. Arthritis & Rheumatology Vol. 69, No. 8, august 2017, pp 1521-1537. DOI 10.1002/art.40137. [3]Fardet L, Petersen I, Nazareth I. Monitoring of patients on long-term glucocorticoid therapy: a population-based cohort study. Medicine (Baltimore). 2015 Apr;94(15):e647. doi: 10.1097/MD.0000000000000647. Disclosure of Interests: None declared
Keywords: treatment / bone mineral density / GIO / Rheumatology / providing education / pre and post / guideline / Fracture / Osteoporosis

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