GIO SCOPE supports appropriate prescribing in older people at risk of steroid-induced osteoporosis, says Professor Juliet Compston
Evidence-based guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis, developed by the Bone and Tooth Society of Great Britain, the National Osteoporosis Society and the Royal College of Physicians, were published in December 2002.
The guidelines stress the need for primary prevention of bone loss in individuals at high risk who are commencing oral glucocorticoid therapy, regardless of dose, and likely to continue for a minimum of three months.Those defined at high risk of fracture are men and women aged 65 years and over and those with a previous fragility fracture. Coprescription of a bone-protective agent is recommended for all such individuals, without the need for bone mineral density measurement.
Several agents have been assessed for prevention and treatment of glucocorticoid-induced osteoporosis, but only three bisphosphonates (etidronate, alendronate and risedronate) have been approved for this indication.
All three interventions reduce or prevent bone loss at the spine and hip; although fracture reduction has not been a primary outcome of any of the clinical trials, evidence for a decrease in vertebral fracture rate has been obtained from safety data or post hoc analyses, particularly in postmenopausal women.
Following publication of the guidelines, the Clinical Effectiveness and Evaluations Unit of the RCP has developed an audit tool, GIO SCOPE, to evaluate the level of appropriate prescribing of bone-protective agents in glucocorticoid-treated patients aged 65 years and over.
The audit tool can be used on its own or incorporated into the National Sentinel Audit of Evidence Based Prescribing in Older People, which assesses the appropriateness of prescribing in a range of clinical conditions.
The entry point for the algorithm (Figure 1, below) is men and women aged 65 years and over who are receiving oral glucocorticoids. A number of demographic and medical details are then entered, including whether or not a bisphosphonate (cyclic etidronate, alendronate or risedronate) is used.
|Figure 1: Management of glucocorticoid-induced oseteoporosis in men and women|
|Reproduced from Glucocorticoid-induced osteoporosis: A concise guide to prevention and treatment by kind permission of the Royal College of Physicians, Bone and Tooth Society of Great Britain and National Osteoporosis Society|
Inappropriate prescribing is defined as absence of bisphosphonate therapy after excluding the following groups of patients:
- Those who are treated for less than 3 months.
- Those receiving glucocorticoid replacement therapy for adrenal or pituitary failure.
- Those with malignancy or terminal disease.
- Those with contraindications to bisphosphonate therapy.
Appropriate prescribing is defined as absence of bisphosphonate therapy if the above contraindications are present or administration of bisphosphonates if they are absent.
Although the once weekly formulations of alendronate and risedronate are not approved for glucocorticoid-induced osteoporosis, they are considered appropriate in the context of GIO SCOPE, in addition to once daily administration.
Furthermore, although risedronate is not approved for the prevention and treatment of glucocorticoid-induced osteoporosis in premenopausal women and in men, the evidence for its efficacy in these groups is similar to that obtained for alendronate and etidronate, so its use in men and women of all ages is considered appropriate in this audit tool.
Previous surveys have suggested that the rate of prescription of bone-protective agents in individuals using oral glucocorticoids is low, even in those at high risk. GIO SCOPE provides an opportunity to conduct regular reviews of the management of glucocorticoid-induced osteoporosis in clinical practice and to improve standards of care. It is simple to use and, although the pilot studies have been conducted in secondary care settings, it is well suited for use in primary care.
GIO SCOPE, produced as a CD, is available from the RCP publications department, price £5, tel: 020 7935 1174 ext 254.