Fracture Prevention Care Lacking Among Older Patients Receiving Oral Corticosteroids

Older adults who were prescribed high cumulative oral corticosteroid doses across multiple prescriptions or with many long gaps between prescriptions were about half as likely to receive guideline-indicated fracture prevention care compared with patients who received similar oral corticosteroid doses in 1 prescription or within a short period of time, according to study results published in JAMA Dermatology.

Researchers conducted parallel cohort studies using data from the UK (January 1998 to January 2020) and Ontario, Canada (April 2002 to September 2020). They sought to estimate the association between different patterns of oral corticosteroid prescribing and appropriate fracture prevention care among older adults with high cumulative exposure to oral corticosteroids due to relapsing-remitting conditions, such as eczema, asthma, and chronic obstructive pulmonary disease (COPD).

The UK study used deidentified primary care data from Clinical Practice Research Datalink GOLD, and the Ontario study used population-based primary and secondary care administrative data from ICES (previously Institute for Clinical Evaluative Sciences). The researchers evaluated data on patients with eczema, asthma, or COPD aged 66 years and older who exceeded the cumulative oral corticosteroid high-risk dose threshold of 450 mg of the prednisolone-equivalent dose within the previous 6 months. The analysis included 65,195 patients from the UK study (mean age, 75 [interquartile range {IQR}, 71-81] years; 50.6% men), and 28,674 patients from the Ontario study (mean age, 73 [IQR, 69-79] years; 59.5% men).

For the primary exposure, the researchers classified patients as either having low-intensity (90 days or longer to cross the risk threshold) or high-intensity (fewer than 90 days to cross the risk threshold) oral corticosteroid prescriptions. The primary outcome was prescriptions for fracture-prevention medications, which are recommended in guidelines for this population and include bisphosphonates, bazedoxifene, burosumab, raloxifene, and teriparatide.

In the UK study, 1 year after the index date, 8.9% of patients who had reached the risk threshold of a 450-mg prednisolone-equivalent dose had received fracture prevention care medication, with 10.7% receiving high-intensity oral corticosteroid prescriptions and 4.8% receiving low-intensity prescriptions (crude rates, 134 vs 57 per 1000 person-years; crude hazard ratio [HR], 2.34; 95% CI, 2.19-2.51; adjusted HR, 2.13; 95% CI, 1.99-2.29).

In the Ontario study, at 1 year after the index date, 6.1% of patients who had reached the risk threshold of a 450-mg prednisolone-equivalent dose had received fracture prevention care, with 6.4% receiving high-intensity oral corticosteroid prescriptions and 4.4% receiving low-intensity prescriptions (crude rates, 73 vs 48 per 1000 person-years, respectively; crude HR, 1.49; 95% CI, 1.29-1.72; adjusted HR, 1.47; 95% CI, 1.27-1.70).

In analyses with disease subgroups that compared patients with high-intensity vs low-intensity oral corticosteroid prescriptions, the highest HRs for being prescribed fracture prevention care were in patients with COPD (HR, 1.58; 95% CI, 1.30-1.91) and those with asthma (HR, 1.42; 95% CI, 1.07-1.88). No substantially increased risk was observed for patients with eczema (HR, 1.15; 95% CI, 0.89-1.50).

At the end of the UK study, 5.1% of patients who had reached the risk threshold with high-intensity oral corticosteroid prescriptions had experienced a major osteoporotic fracture, vs 4.7% with low-intensity prescriptions (crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15; adjusted HR, 1.12; 95% CI, 1.03-1.21).

At the end of the Ontario study, 10.3% of patients who had reached the risk threshold with high-intensity oral corticosteroid prescriptions had experienced a major osteoporotic fracture, vs 10.1% with low-intensity prescriptions (crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96; adjusted HR, 0.91; 95% CI, 0.73-1.12).

Among several limitations, the study lacked data regarding medication adherence. The UK study only included information about whether the prescription was written, and the Ontario study only included information about whether the prescription was filled. Additionally, other unmeasured confounders such as frailty may account for the association between oral corticosteroid prescribing patterns, receiving fracture prevention care, and experiencing fractures.

The researchers concluded, “These findings suggest missed opportunities to initiate fracture prevention for older people prescribed oral corticosteroids.” They added, “Clinicians, including dermatologists, respirologists, general practitioners, and internists, should be aware of recent cumulative oral corticosteroid dose, regardless of the prescribing pattern, and initiate fracture preventive care if indicated.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Dermatology Advisor