Rheumatology Unit, Gartnavel General Hospital, Glasgow, UK
SIR, We read with interest the article by Erb et al. [1] on prevention and treatment of corticosteroid-induced osteoporosis. Osteoporosis is a major public health problem, with significant morbidity and mortality, and an estimated annual cost of £940 million to the NHS [2]. Despite published guidelines it is difficult to meet the targets set. Rheumatologists have a particular responsibility because most patients receiving long-term systemic corticosteroid treatment have a rheumatological disorder.
Using the Royal College of Physicians (RCP) guidelines (2001) [2], we performed an audit of our current practice relating to corticosteroid treatment. Our rheumatology department has a continually updated database of over 15 000 current and past patients. This contains information on patients' demographics, the primary rheumatological diagnosis, comorbid conditions, current drug treatment and past treatments (including corticosteroids), and it interacts with the hospital information system, which records all patient-generated events, including out- and in-patient episodes.
Forty patients who were currently or previously had been on prednisolone at a dose of at least 7.5 mg/day for 6 months or more were selected at random and interviewed, and their case records and database entries were reviewed.
As in the regional level audit undertaken by Erb et al. (the Midlands study), we recorded information on patient demographics, current/previous dose of corticosteroids, conditions for which steroids were being prescribed, history of low-trauma fracture, menopausal status in females, previous dual-energy X-ray absorption (DEXA) scan and any current treatment or prophylaxis that the patient was receiving.
However, unlike Erb et al., we also gathered data on additional synergistic risk factors for osteoporosis, such as a family history of osteoporosis in a first-degree relative, smoking, alcohol intake, comorbid conditions and the use of a corticosteroid inhaler. We also enquired about loss of height and the presence of kyphosis.
Only 60% of our patients on long-term steroids had undergone a DEXA scan. This highlights that there is much needed to be done to reach the 100% suggested by the clinical guidelines set by the RCP.
For the 40 patients who participated in the survey, the mean age was 60 yr (range 2686 yr). Seventy per cent were female. Ninety-five per cent were using corticosteroids, primarily because of a rheumatological condition. Of the 28 women surveyed, 21 (75%) were post-menopausal. Eight of these had undergone menopause before age 45 yr. There was a positive family history in four patients (10%). Only 33% of the patients surveyed took regular exercise (defined as at least 30 min three times a week), though 95% of patients had taken regular exercise as teenagers. Thirty-three per cent reported a diet low in calcium (i.e. little or no dairy products), 40% stating they had a diet low in calcium as teenagers. Thirty-five per cent smoked and one patient admitted to an alcohol problem. Twenty-three per cent of the patients were on a steroid inhaler regularly for asthma or chronic obstructive pulmonary disease concurrently with their oral steroid prescription. Ninety per cent had at least one further risk factor for osteoporosis (other than steroid use), and 18% had three or more. Six patients had sustained a fracture with minimal injury, 14 had noticed a reduction in height and nine had noticed they were becoming increasingly stooped.
Sixty per cent of patients had had at least one DEXA scan and 23% had had more than one. Of the 24 scanned, nine had normal bone mineral density, nine had some evidence of osteopenia and three had osteoporosis. The results of the scan in a further three patients are awaited.
Drug treatment/prophylaxis had been prescribed in 93% of patients. One patient was not taking the medication, even though it was prescribed, and the other three were not prescribed any. Four patients were receiving calcium supplementation without vitamin D, 18 were receiving calcium and vitamin D, 19 were taking bisphosphonates, one was on hormone replacement therapy and one on calcitonin. None were on Selective estrogen-receptor modulators (SERMs).
Our audit produced similar results to those of Erb et al. with regard to medication use, with a remarkably consistent proportion receiving bisphosphonates (48% in our study, 47% in the Midlands study), and an overall similar amount receiving calcium with or without vitamin D (55% in our study, 53% in theirs). However, the proportion of those prescribed calcium alone in our study was much lower. In the Midlands study, 43.4% of patients had had a DEXA scan compared with 60% in our study.
The National Osteoporosis Society (NOS) guidelines [3] consider calcium with or without vitamin D alone to be inadequate prophylaxis or treatment for steroid-induced osteoporosis in those who fall into any of the following categories: are over 65 yr, taking over 15 mg/day of steroids, have a previous fracture, or other strong risk factors (e.g. family history, immobility, evidence of decreased bone mineral density). The fact that many of the patients in our study and the Midlands study were taking calcium with or without vitamin D alone, including those with documented evidence of osteopenia in our study and those who are taking high doses of steroids, is still unsatisfactory if these guidelines are taken as a gold standard. If each patient case is examined and classified as adequately treated or not according to the NOS guidelines, then 73% of the patients in our study are adequately treated. In the Midlands study, 63% of the patients were being appropriately treated when classified in this way. However, when additional risk factors are taken into account, as suggested in the RCP guidelinesnamely, diseases associated with increased prevalence of osteoporosis (e.g. gastrointestinal disease, chronic liver disease), family history, cigarette smoking and height lossonly 50% of our patients were adequately treated.
While the Midlands study might appear encouraging, we suggest that other risk factors must be considered when making a decision on management for patients taking steroids, as in many cases these may alter the appropriate treatment choice.
Notes
Correspondence to: J. Hunter, Rheumatology Unit, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK. E-mail: john.hunter.wg{at}northglasgow.scot.nhs.uk
References