Older individuals may require more attention if they receive high cumulative oral corticosteroid doses with gaps between their prescriptions, according to recent findings, given that they may not be given the chance to get fracture preventative care.¹

The study’s investigators note that oral corticosteroid prescriptions are frequently given out in brief and discontinuous bursts to address flares of relapsing-remitting diseases, such as eczema, and chronic obstructive pulmonary disease (COPD), among others.²

The research was conducted with the overall goal of examining and then mitigating potential gaps in preventative care to reduce the overall high rates of mortality linked to fractures, and the research was authored by Aaron M. Drucker, MD, ScM, from Women’s College Hospital in Toronto, Canada.³

“The objective of this study was to determine whether oral corticosteroid prescribing patterns were differentially associated with receiving guideline-recommended fracture preventive care among older adults with eczema, asthma, or COPD,” Drucker and colleagues wrote.

Background and Findings

The investigators’ cohort study involved use of 65,195 individuals whose electronic medical record information was drawn from the UK’s Clinical Practice Research Datalink, with the data being from January of 1998 to January of 2020. Additionally, 28,674 individuals were included with health administrative data featured in ICES in Ontario, Canada from April of 2002 to September of 2020.

The team’s research assessed adults who were aged 66 years or older and had been given prescriptions for oral corticosteroids to address conditions including asthma, eczema, or COPD. The individuals’ prescriptions needed a cumulative prednisolone equivalent dose of 450 mg or more and to be within a 6-month timeframe.

The investigators’ analysis of data was initiated from October of 2020 to September of 2022. In terms of exposures, the study participants were labeled based upon the rate of crossing the 450-mg cumulative oral corticosteroid threshold.

The individuals who were able to cross this particular threshold in fewer than 90 days were given a label of having ‘high-intensity prescriptions,’ while those who needed 90 days or more were considered to have ‘low-intensity prescriptions.’ Several different alternative exposure definitions were examined in the team’s sensitivity analyses.

The research team’s main focus was examining prescribed fracture preventive care as the principal outcome in their work. Additionally, the team assessed major osteoporotic fractures as a secondary outcome.

The study’s participants were followed by the investigators from the time they crossed the oral corticosteroid threshold up until their respective outcomes or the time of their finishing the follow-up section, which extended up to a single year following the index date.

The research team calculated fracture preventive care rates as well as fractures, and they utilized Cox proportional hazards regression models in order to determine hazard ratios (HRs). These HRs were utilized to compare the effects of high-intensity oral corticosteroid prescriptions to low-intensity prescriptions.

Overall, the investigators noted that both the Ontario and the UK cohorts featured a substantial number of participants, with varying ages as well as gender distributions. The team reported that older adults who were given ‘high-intensity’ oral corticosteroid prescriptions showed considerably higher rates of fracture preventive care versus those with low-intensity prescriptions.

In the team’s UK group, rates were found to have been 134 versus 57 per 1000 person-years, resulting in a crude HR of 2.34 (95% CI, 2.19 - 2.51). Meanwhile in the Ontario group, the rates were found to have been 73 versus 48 per 1000 person-years, yielding a crude HR of 1.49 (95% CI, 1.29 - 1.72).

Notably, the investigators found no substantial difference in the occurrence of major osteoporotic fractures between those who had high- or low-intensity oral corticosteroid prescriptions.

“These findings suggest missed opportunities to initiate fracture prevention for older people prescribed oral corticosteroids,” they wrote. “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.”

References

1. ^{Matthewman J, Tadrous M, Mansfield KE, et al. Association of Different Prescribing Patterns for Oral Corticosteroids With Fracture Preventive Care Among Older Adults in the UK and Ontario. JAMA Dermatol. Published online August 09, 2023. doi:10.1001/jamadermatol.2023.2495.}
2. ^{Alexander T, Maxim E, Cardwell LA, Chawla A, Feldman SR. Prescriptions for atopic dermatitis: oral corticosteroids remain commonplace. J Dermatolog Treat. 2018;29(3):238-240. doi:10.1080/09546634.2017.1365112.}
3. ^{Nazrun AS, Tzar MN, Mokhtar SA, Mohamed IN. A systematic review of the outcomes of osteoporotic fracture patients after hospital discharge: morbidity, subsequent fractures, and mortality. Ther Clin Risk Manag. 2014;10:937-948.}