Osteoporosis Prevention in Inhaled Cortico-steroid Users

Principle Investigators: Hoan Linh Banh, Pharm.D

Andrew Cave, MBChB MClSc

Valerie Chan, BScPharm

ACFP:ASA Banff Feb27th 2014

Conflicts of InterestDr Banh and Ms Chan have no

conflicts to declareDr Cave has received research

support from GSK, Astra-Zeneca, Novartis. Merck Canada, Grifols, Boeringer-Ingelheim but has no conflict related to this study

IntroductionInhaled corticosteroids (ICS):

◦standard maintenance therapy in controlling symptoms in asthma patients

◦and add on in moderate to severe chronic obstructive pulmonary disease (COPD)

Risk of osteoporosis with systemic corticosteroid use is well known but there is low awareness of risk with ICS

GINA Guidelines

Patients on (1) High doses ICS (defined as >2 mg beclomethason/day) OR (2) Oral glucocorticosteroids (any dose)

are considered at risk of developing osteoporosis and fractures.

Osteoporosis PreventionCalcium supplementation

◦Age 19-50: 1000 mg/day◦Age >50: 1200 mg/day

Vitamin D supplementation◦Age <50: 400 IU/day ◦Age >50: 800-2000 IU/day

Lifestyle Modifications◦Smoking Cessation◦Exercise◦Limit alcohol intake

ObjectivesPrimary: To investigate the extent of

osteoporosis prevention or treatment received by patients with asthma and COPD treated with ICS.

Secondary: To assess the number of patients, regardless of ICS dose, who met the requirements for an initial BMD scan, received the BMD and received appropriate follow up when indicated.

Methodology

Inclusion:◦Age ≥19 years◦ICS use ≥ 3 months in the past 12

months◦Willing to answer a questionnaire

Exclusion:◦Difficulty speaking English or

cognitively impaired

Results

- N = 255- Overall mean age = 60 years (SD = 17.4 years)- 66% Female – mean age 61 (SD = 17.1 years)- 34% Male – mean age 57 (SD = 17.7 years)

Results

Results

Results

Results

Results

> or = 65 years old < 65 years old0

10

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60

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Number of patients who received appropriate or pending BMD follow up vs. inappropriate BMD follow up

InappropriateAppropriate or pending

Num

ber

of p

atien

ts

Results SummarySubjects are more than twice as likely to

take appropriate vitamin D than calciumTaking apprpriate Vitamin D and Calcium

◦Low ICS users = 19%◦Medium ICS users = 21%◦High ICS users = 8%

Having appropriate osteoporosis prophylaxis or being treated for OP◦Low ICS users = 28%◦Medium ICS users = 30%◦High ICS users = 26%

Results Summary 2

29% of subjects(73/255) were found to be sufficiently supplemented or treated, regardless of dose potency

Either by adequate intake of both calcium and

vitamin D (45 patients) treated for osteoporosis (28 patients)

Discussion

◦High dose ICS users: (at highest risk)

62% ≥ 65 years old (age increases OP risk)

Had lowest appropriate intake of calcium at 13% (7/53)

? Pill size issue, constipation in older age

Discussion

BMD:◦Majority of eligible subjects received

an initial scan and appropriate follow up

DiscussionStudy Limitations and Difficulties

◦Health Information Act Data may not represent all of Alberta

◦Restrictions imposed by pharmacy authority

◦Pharmacy settings with a low rate of returning patients

◦Subjective reporting Some subjects could not recall exact year

that they received follow up of BMD Dietary intake of vitamin D and calcium

hard to assess

Conclusion< 29% of patients are achieving

appropriate osteoporosis prophylaxis or treatment regardless of ICS dose

◦high dose ICS users (highest need of osteoporosis prevention) have lowest prevention/treatment rate (26%)

For patients who qualified for an initial BMD test, 61% received it.

AcknowledgementsCostco #544 – Sherwood Park, Alberta Shoppers Drug Mart #302 – Edmonton, AlbertaShoppers Drug Mart #312 – Edmonton, AlbertaShoppers Drug Mart #346 – Edmonton, AlbertaShoppers Drug Mart #386 – Edmonton, AlbertaShoppers Drug Mart #2301 – Edmonton, AlbertaLondon Drugs #22 – Edmonton, AlbertaSafeway Capilano – Edmonton, AlbertaSprucewood Pharmacy – Lloydminster, AlbertaWalmart #3118 – Edmonton, AlbertaWalmart #1570 – Camrose, AlbertaWalmart #7236 – Edmonton, Alberta

Questions?