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Annual Report Year 2

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Improving Management of Steroid-induced Osteoporosis

Caregivers have not followed expert recommendations for people receiving long-term glucocorticoid treatment. So concludes a study from the University of Alabama at Birmingham (UAB) CERTs that appears in the June 2001 issue of the Journal of Rheumatology.

Glucocorticoids, a class of steroid drugs, have been used for more than 50 years to reduce inflammation and suppress the immune system. Prednisone and cortisone are examples of glucocorticoids.

These drugs are invaluable in the treatment of rheumatoid arthritis (RA), lupus erythematosus, and other inflammatory and autoimmune disorders. They are not without risk, however.

One of their side effects is to cause bones to break down more rapidly. They also act directly on the cells that form bone tissue. Together, these two effects can render the bone less dense, and thus weaker, than it should be. This condition is known as osteoporosis.

Glucocorticoid-induced osteoporosis (GIOP) can be managed by periodically measuring bone mass and using appropriate preventive and therapeutic compounds. These compounds include calcium or vitamin D supplements, estrogens, and newer nonhormonal drugs to prevent bone loss, such as alendronate and residronate.

Since 1996, guidelines from the American College of Rheumatology have recommended the strategies described above for prevention and treatment of GIOP. With support from partners Aetna U.S. Healthcare, U.S. Quality Algorithms, and Merck & Co., Inc., the UAB CERTs examined how well caregivers have followed these recommendations.

“…only a minority of physicians are addressing this critical problem.”

They studied 2378 HMO members who, over a 3-year period, had received a new prescription for at least a 3-month supply of glucocorticoids.

The news, although better than in previous studies, remains discouraging. Overall, only 9% of the members had undergone bone-mass measurement, and only 21% of the members had been prescribed any kind of treatment for osteoporosis. "Our findings are regrettably consistent with past studies in showing that only a minority of physicians are addressing this critical problem," said Amy Mudano, MPH, lead author of the study.

Women over the age of 50 fared somewhat better: 16% had undergone measurement of bone mass overall, and 41% had been prescribed preventive therapy independent of testing.

Although rheumatologists were most likely to have followed the guidelines, still, only 18% of them had ordered a bone-mass measurement and only 30% had prescribed the appropriate therapies.

Clearly, there is a need for education of caregivers and patients.

The UAB CERTs now is conducting a project to test how outcomes are affected by different interventions designed to increase the use of these agents.

"We intend to use well-tested methods developed at UAB for changing physician behavior," says Dr. Kenneth Saag, principal investigator of the UAB CERTs.

The interventions will include a Web-based resource for physician education, feedback on performance, and printable materials on prevention and treatment of GIOP.

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