Osteoporosis International

, Volume 22, Issue 1, pp 305–315 | Cite as

An observational study of glucocorticoid-induced osteoporosis prophylaxis in a national cohort of male veterans with rheumatoid arthritis

  • L. Caplan
  • A. E. Hines
  • E. Williams
  • A. V. Prochazka
  • K. G. Saag
  • F. Cunningham
  • E. Hutt
Original Article



We applied regression techniques to a large cohort of patients to understand why certain patients are prescribed medications to prevent glucocorticoid-induced osteoporosis (GIO). Rates of prescriptions to prevent osteoporosis were low. The presence of drugs and disorders associated with osteoporosis and gastrointestinal conditions actually are associated with a decreased likelihood of receiving osteoporosis-preventing medications.


To understand why some patients are prescribed medications to prevent GIO while other patients are not, we examined whether there is an association among osteoporosis-inducing medical conditions or medications and prescriptions for osteoporosis prophylaxis in a large cohort of rheumatoid arthritis patients on chronic glucocorticoids.


Department of Veterans’ Affairs national administrative databases were used to construct a cohort (n = 9,605) and provide the data for this study. Multivariate logistic regression was performed to determine medical conditions and medications associated with dispensing of GIO-preventive medications, controlling for sociodemographic variables, comorbidities, glucocorticoid dosage, prior fractures, and rheumatoid arthritis severity. A subanalysis examined predictors of early GIO prevention.


Subjects were more likely to receive GIO prophylaxis if they were older, African American, treated with multiple antirheumatic disease-modifying drugs, or received greater glucocorticoid exposure. The prescription of certain drug classes (loop diuretics and anticonvulsants) and conditions (malignancy, renal insufficiency, alcohol abuse, and hepatic disease) were associated with lower likelihood of GIO prophylaxis, despite putative links between these agents/conditions and osteoporosis. The presence of gastrointestinal disorders dramatically decreased likelihood of GIO prophylaxis. Few characteristics predicted the dispensing of GIO-preventing medications within 7 days of the initial glucocorticoid start date.


Rates of prescriptions to prevent osteoporosis in a cohort of older men with rheumatoid arthritis on chronic glucocorticoids were low. Gastrointestinal disorders and drugs and disorders potentially linked to osteoporosis are associated with diminished odds of being prescribed GIO-preventing medications.


Adverse effects Glucocorticoids Osteoporosis Prevention 



This project was supported by funding from the VA Health Services Research and Development service. Dr. Caplan is supported by a VA HSR&D Career Development Award.

Conflicts of interest

We declare that we have no financial and personal relationships with other people or organizations that could inappropriately influence (bias) this work, including employment, consultancies, stock ownership, honoraria, paid expert testimony, patents or patent applications, and travel grants, all within 5 years of beginning the work submitted. The manuscript has not been published, submitted, nor is not simultaneously being submitted elsewhere.


  1. 1.
    Melton LJ III (1995) How many women have osteoporosis now? J Bone Miner Res 10:175–177CrossRefPubMedGoogle Scholar
  2. 2.
    Van Staa TP, Leufkens HG, Abenhaim L, Begaud B, Zhang B, Cooper C (2000) Use of oral corticosteroids in the United Kingdom. QJM 93:105–111CrossRefPubMedGoogle Scholar
  3. 3.
    Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C (2000) Use of oral corticosteroids and risk of fractures. J Bone Miner Res 15:993–1000CrossRefPubMedGoogle Scholar
  4. 4.
    American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. Arthritis Rheum 44:1496–1503CrossRefGoogle Scholar
  5. 5.
    Adler RA, Hochberg MC (2003) Suggested guidelines for evaluation and treatment of glucocorticoid-induced osteoporosis for the Department of Veterans Affairs. Arch Intern Med 163:2619–2624CrossRefPubMedGoogle Scholar
  6. 6.
    Compston JE (2007) Emerging consensus on prevention and treatment of glucocorticoid-induced osteoporosis. Curr Rheumatol Rep 9:78–84CrossRefPubMedGoogle Scholar
  7. 7.
    Adachi JD, Olszynski WP, Hanley DA, Hodsman AB, Kendler DL, Siminoski KG, Brown J, Cowden EA, Goltzman D, Ioannidis G, Josse RG, Ste-Marie LG, Tenenhouse AM, Davison KS, Blocka KL, Pollock AP, Sibley J (2000) Management of corticosteroid-induced osteoporosis. Semin Arthritis Rheum 29:228–251CrossRefPubMedGoogle Scholar
  8. 8.
    Sambrook PN, Diamond T, Ferris L, Fiatarone-Singh M, Flicker L, MacLennan A, Nowson C, O’Neill S, Greville H (2001) Corticosteroid induced osteoporosis. Guidelines for treatment. Aust Fam Physician 30:793–796PubMedGoogle Scholar
  9. 9.
    Nawata H, Soen S, Takayanagi R, Tanaka I, Takaoka K, Fukunaga M, Matsumoto T, Suzuki Y, Tanaka H, Fujiwara S, Miki T, Sagawa A, Nishizawa Y, Seino Y (2005) Guidelines on the management and treatment of glucocorticoid-induced osteoporosis of the Japanese Society for Bone and Mineral Research (2004). J Bone Miner Metab 23:105–109CrossRefPubMedGoogle Scholar
  10. 10.
    Devogelaer JP, Goemaere S, Boonen S, Body JJ, Kaufman JM, Reginster JY, Rozenberg S, Boutsen Y (2006) Evidence-based guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int 17:8–19CrossRefPubMedGoogle Scholar
  11. 11.
    Geusens PP, Lems WF, Verhaar HJ, Leusink G, Goemaere S, Zmierczack H, Compston J (2006) Review and evaluation of the Dutch guidelines for osteoporosis. J Eval Clin Pract 12:539–548CrossRefPubMedGoogle Scholar
  12. 12.
    Ettinger B, Chidambaran P, Pressman A (2001) Prevalence and determinants of osteoporosis drug prescription among patients with high exposure to glucocorticoid drugs. Am J Manag Care 7:597–605PubMedGoogle Scholar
  13. 13.
    Buckley LM, Marquez M, Hudson JO, Downs RW, Vacek P, Small RE, Poses R (1998) Variations in physicians’ judgments about corticosteroid induced osteoporosis by physician specialty. J Rheumatol 25:2195–2202PubMedGoogle Scholar
  14. 14.
    Saag KG, Gehlbach SH, Curtis JR, Youket TE, Worley K, Lange JL (2006) Trends in prevention of glucocorticoid-induced osteoporosis. J Rheumatol 33:1651–1657PubMedGoogle Scholar
  15. 15.
    Solomon DH, Katz JN, Jacobs JP, La Tourette AM, Coblyn J (2002) Management of glucocorticoid-induced osteoporosis in patients with rheumatoid arthritis: rates and predictors of care in an academic rheumatology practice. Arthritis Rheum 46:3136–3142CrossRefPubMedGoogle Scholar
  16. 16.
    Elliott ME, Farrah RM, Binkley NC, Carnes ML, Gudmundsson A (2000) Management of glucocorticoid-induced osteoporosis in male veterans. Ann Pharmacother 34:1380–1384PubMedGoogle Scholar
  17. 17.
    Feldstein AC, Elmer PJ, Nichols GA, Herson M (2005) Practice patterns in patients at risk for glucocorticoid-induced osteoporosis. Osteoporos Int 16:2168–2174CrossRefPubMedGoogle Scholar
  18. 18.
    Solomon DH, Katz JN, La Tourette AM, Coblyn JS (2004) Multifaceted intervention to improve rheumatologists’ management of glucocorticoid-induced osteoporosis: a randomized controlled trial. Arthritis Rheum 51:383–387CrossRefPubMedGoogle Scholar
  19. 19.
    Curtis JR, Westfall AO, Allison J, Becker A, Melton ME, Freeman A, Kiefe CI, MacArthur M, Ockershausen T, Stewart E, Weissman N, Saag KG (2007) Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial. Arch Intern Med 167:591–596CrossRefPubMedGoogle Scholar
  20. 20.
    Chitre MM, Hayes W (2008) 3-year results of a member and physician intervention to reduce risk associated with glucocorticoid-induced osteoporosis in a health plan. J Manag Care Pharm 14:281–290PubMedGoogle Scholar
  21. 21.
    Aagaard EM, Lin P, Modin GW, Lane NE (1999) Prevention of glucocorticoid-induced osteoporosis: provider practice at an urban county hospital. Am J Med 107:456–460CrossRefPubMedGoogle Scholar
  22. 22.
    Mudano A, Allison J, Hill J, Rothermel T, Saag K (2001) Variations in glucocorticoid induced osteoporosis prevention in a managed care cohort. J Rheumatol 28:1298–1305PubMedGoogle Scholar
  23. 23.
    Duyvendak M, Naunton M, Atthobari J, van den Berg PB, Brouwers JR (2007) Corticosteroid-induced osteoporosis prevention: longitudinal practice patterns in The Netherlands 2001-2005. Osteoporos Int 18:1429–1433CrossRefPubMedGoogle Scholar
  24. 24.
    Singh JA, Holmgren AR, Noorbaloochi S (2004) Accuracy of veterans Administration databases for a diagnosis of rheumatoid arthritis. Arthritis Rheum 51:952–957CrossRefPubMedGoogle Scholar
  25. 25.
    Curtis JR, Westfall AO, Allison JJ, Freeman A, Saag KG (2006) Channeling and adherence with alendronate and risedronate among chronic glucocorticoid users. Osteoporos Int 17:1268–1274CrossRefPubMedGoogle Scholar
  26. 26.
    Van Staa TP, Leufkens HG, Cooper C (2002) The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporos Int 13:777–787CrossRefPubMedGoogle Scholar
  27. 27.
    Shekelle P, Munjas B, Liu H, Paige N, Zhou A (2007) Screening men for osteoporosis: who & how. Department of Veterans Affairs (HSR&D Evidence Synthesis Pilot Program), Washington, DCGoogle Scholar
  28. 28.
    Chrousos GP (2001) Glucocorticoid therapy. In: Felig P, Frohman L (eds) Endocrinology and metabolism, 4th edn, Chap 14. McGraw-Hill, New York, pp 609–632Google Scholar
  29. 29.
    Mikuls TR, Saag KG, George V, Mudano AS, Banerjee S (2005) Racial disparities in the receipt of osteoporosis related healthcare among community-dwelling older women with arthritis and previous fracture. J Rheumatol 32:870–875PubMedGoogle Scholar
  30. 30.
    Cruse LM, Valeriano J, Vasey FB, Carter JD (2006) Prevalence of evaluation and treatment of glucocorticoid-induced osteoporosis in men. J Clin Rheumatol 12:221–225CrossRefPubMedGoogle Scholar
  31. 31.
    Schneeweiss S, Seeger JD, Maclure M, Wang PS, Avorn J, Glynn RJ (2001) Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data. Am J Epidemiol 154:854–864CrossRefPubMedGoogle Scholar
  32. 32.
    Schneeweiss S, Wang PS, Avorn J, Glynn RJ (2003) Improved comorbidity adjustment for predicting mortality in Medicare populations. Health Serv Res 38:1103–1120CrossRefPubMedGoogle Scholar
  33. 33.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778CrossRefPubMedGoogle Scholar
  34. 34.
    Tromp AM, Ooms ME, Popp-Snijders C, Roos JC, Lips P (2000) Predictors of fractures in elderly women. Osteoporos Int 11:134–140CrossRefPubMedGoogle Scholar
  35. 35.
    Petty SJ, O’Brien TJ, Wark JD (2007) Anti-epileptic medication and bone health. Osteoporos Int 18:129–142CrossRefPubMedGoogle Scholar
  36. 36.
    Sheppard MC, Holder R, Franklyn JA (2002) Levothyroxine treatment and occurrence of fracture of the hip. Arch Intern Med 162:338–343CrossRefPubMedGoogle Scholar
  37. 37.
    Mezuk B, Eaton WW, Golden SH (2008) Depression and osteoporosis: epidemiology and potential mediating pathways. Osteoporos Int 19:1–12CrossRefPubMedGoogle Scholar
  38. 38.
    Vestergaard P (2007) Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes–a meta-analysis. Osteoporos Int 18:427–444CrossRefPubMedGoogle Scholar
  39. 39.
    Saad F, Adachi JD, Brown JP, Canning LA, Gelmon KA, Josse RG, Pritchard KI (2008) Cancer treatment-induced bone loss in breast and prostate cancer. J Clin Oncol 26:5465–5476CrossRefPubMedGoogle Scholar
  40. 40.
    Melton LJ III, Kyle RA, Achenbach SJ, Oberg AL, Rajkumar SV (2005) Fracture risk with multiple myeloma: a population-based study. J Bone Miner Res 20:487–493CrossRefPubMedGoogle Scholar
  41. 41.
    Berg KM, Kunins HV, Jackson JL, Nahvi S, Chaudhry A, Harris KA Jr, Malik R, Arnsten JH (2008) Association between alcohol consumption and both osteoporotic fracture and bone density. Am J Med 121:406–418CrossRefPubMedGoogle Scholar
  42. 42.
    Cunningham J, Sprague SM, Cannata-Andia J, Coco M, Cohen-Solal M, Fitzpatrick L, Goltzmann D, Lafage-Proust MH, Leonard M, Ott S, Rodriguez M, Stehman-Breen C, Stern P, Weisinger J (2004) Osteoporosis in chronic kidney disease. Am J Kidney Dis 43:566–571CrossRefPubMedGoogle Scholar
  43. 43.
    Gal-Moscovici A, Sprague SM (2007) Osteoporosis and chronic kidney disease. Semin Dial 20:423–430CrossRefPubMedGoogle Scholar
  44. 44.
    Trautwein C, Possienke M, Schlitt HJ, Boker KH, Horn R, Raab R, Manns MP, Brabant G (2000) Bone density and metabolism in patients with viral hepatitis and cholestatic liver diseases before and after liver transplantation. Am J Gastroenterol 95:2343–2351CrossRefPubMedGoogle Scholar
  45. 45.
    Mounach A, Ouzzif Z, Wariaghli G, Achemlal L, Benbaghdadi I, Aouragh A, Bezza A, El MA (2008) Primary biliary cirrhosis and osteoporosis: a case-control study. J Bone Miner Metab 26:379–384CrossRefPubMedGoogle Scholar
  46. 46.
    Perreault S, Dragomir A, Desgagne A, Blais L, Rossignol M, Blouin J, Moride Y, Ste-Marie LG, Fernandes JC (2005) Trends and determinants of antiresorptive drug use for osteoporosis among elderly women. Pharmacoepidemiol Drug Saf 14:685–695CrossRefPubMedGoogle Scholar
  47. 47.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465CrossRefPubMedGoogle Scholar
  48. 48.
    Alexopoulou A, Dourakis SP, Mantzoukis D, Pitsariotis T, Kandyli A, Deutsch M, Archimandritis AJ (2008) Adverse drug reactions as a cause of hospital admissions: a 6-month experience in a single center in Greece. Eur J Intern Med 19:505–510CrossRefPubMedGoogle Scholar
  49. 49.
    Liao HL, Chen JT, Ma TC, Chang YS (2008) Analysis of drug-drug interactions (DDIs) in nursing homes in Central Taiwan. Arch Gerontol Geriatr 47:99–107CrossRefPubMedGoogle Scholar
  50. 50.
    Perkins AJ, Kroenke K, Unutzer J, Katon W, Williams JW, Hope C, Callahan CM (2004) Common comorbidity scales were similar in their ability to predict health care costs and mortality. J Clin Epidemiol 57:1040–1048CrossRefPubMedGoogle Scholar
  51. 51.
    Lurk JT, DeJong DJ, Woods TM, Knell ME, Carroll CA (2004) Effects of changes in patient cost sharing and drug sample policies on prescription drug costs and utilization in a safety-net-provider setting. Am J Health Syst Pharm 61:267–272PubMedGoogle Scholar
  52. 52.
    Li X, Guh D, Lacaille D, Esdaile J, Anis AH (2007) The impact of cost sharing of prescription drug expenditures on health care utilization by the elderly: own- and cross-price elasticities. Health Policy 82:340–347CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2010

Authors and Affiliations

  • L. Caplan
    • 1
    • 2
    • 6
  • A. E. Hines
    • 1
  • E. Williams
    • 1
  • A. V. Prochazka
    • 1
    • 2
  • K. G. Saag
    • 3
    • 4
  • F. Cunningham
    • 5
  • E. Hutt
    • 1
    • 2
  1. 1.Denver VA Medical CenterDenverUSA
  2. 2.University of Colorado School of MedicineDenverUSA
  3. 3.Center for Education and Research on Therapeutics of Musculoskeletal DisordersUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.University of Alabama at Birmingham School of MedicineBirminghamUSA
  5. 5.Veterans Affairs Pharmacy Benefits ManagementHinesUSA
  6. 6.University of Colorado DenverDenverUSA

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