Atopic eczema, asthma and COPD are commonly treated with oral corticosteroids (OCS). OCS increase fracture risk. Guidelines recommend fracture preventive care (bone mineral density measurements or fracture-preventive medications, including bisphosphonates) when individuals are prescribed >=450mg prednisolone equivalent dose in 6 months. People are prescribed OCS in different patterns (e.g., continuously or intermittently). We hypothesised people receiving intermittent OCSs were less likely to receive adequate fracture-preventive care than people receiving the same cumulative OCS dose continuously. We conducted a nationwide cohort study using routinely collected UK general practice data. We identified 62,771 individuals aged 66+ with atopic eczema, asthma or COPD who had received at least 450mg prednisolone equivalent dose in 6 months. Estimated hazard ratios from Cox regression suggested those prescribed continuous OCSs had higher fracture preventive care rates than those prescribed intermittent OCSs (adjusted HR 6.65; 95%CI 6.24-7.08). In sensitivity analyses using different continuous/intermittent OCS definitions effect estimates attenuated, but a strong positive association remained. Those prescribed OCS continuously were at higher risk of major osteoporotic fractures (adjusted HR 1.44 95%CI 1.28-1.62). We saw similar results in replicated analyses in a population-based Ontario, Canada cohort . There may be missed opportunities for appropriate fracture preventative care in people prescribed intermittent OCSs, suggesting treatment guidelines should be updated. Future implementation research could explore potential solutions such as automatic reminders in electronic record software for individuals receiving prescriptions reaching threshold cumulative OCS doses.

BACKGROUND: Oral corticosteroids (OCSs) increase fracture risk. At high cumulative OCS doses (>=450mg prednisolone equivalent dose [PED]), guidelines recommend bone mineral density measurements and fracture preventive care, such as bisphosphonates, especially in older adults. We hypothesised that fracture preventive care prescribing depends not just on a high cumulative OCS dose, but also on OCS prescribing patterns, with potentially missed opportunities for fracture preventive care in people prescribed a high cumulative OCS dose gradually or intermittently.
METHODS: We conducted cohort studies using UK data from the Clinical Practice research Datalink and Ontario data from ICES. We selected older (66+) adults with eczema, asthma or chronic obstructive pulmonary disease (COPD) who received high cumulative OCS doses (defined as >=450 mg PED within the past 6 months). We followed up individuals from the date they crossed the threshold of 450 mg PED, until outcome date (main analysis: prescribed fracture preventive care drugs, secondary analysis: major osteoporotic fracture) or end of follow up (up to one year after index date). Participants reaching the risk threshold in <= 90 days were classified as “high intensity” users, in >90 days as “low intensity” users. We calculated rates of fracture preventive care drugs and fractures and estimated hazard ratios from Cox regression comparing “high intensity” OCS users to “low intensity” OCS users. In sensitivity analyses, we used multiple alternative measures to define OCS prescribing patterns.
RESULTS: In both UK and Ontario cohorts of older people, compared to low intensity OCS users, high intensity OCS users had substantially higher rates of fracture preventive care (UK: 141 vs 62 per 1,000 person-years, crude HR 2.24 95%CI 2.10 to 2.39; Ontario: 73 vs 48 per 1,000 person-years, crude HR 1.49 95%CI 1.29 to 1.72); but a similar rate of major osteoporotic fractures. Our results, alongside results from sensitivity analyses, suggest that reaching a high cumulative OCS dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing.
CONCLUSION: People prescribed high cumulative OCSs over multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care. Implementing tracking of cumulative PED over multiple prescriptions in clinical software may improve adherence to OCS-related fracture prevention guidelines.

ESDR078 - Association between oral corticosteroid prescribing patterns and appropriate fracture preventive care: UK and Ontario population-based cohort studies

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