台灣某醫學中心老年全身紅斑性狼瘡、多發性肌炎、皮肌炎病患因長期使用類固醇所造成的骨質疏鬆症預防施行現況 －－ 與現行美國風濕病醫學會2010年建議作比較

Reality and recommendation: Comparison between current practice patterns in a single center in Taiwan and the ACR 2010 recommendations for glucocorticoid-induced osteoporosis treatment among elderly patients with systemic lupus erythematosus, polymyositis, and dermatomyositis

目的：比較老年之全身紅斑性狼瘡、皮肌炎、多發性肌炎病患因長期使用類固醇造成之骨質疏鬆症之預防治療現況和現行美國風濕病醫學會2010年建議的差異。方法：我們收集了北部某醫學中心38位在2009年10月時年齡大於65歲的全身紅斑性狼瘡、皮肌炎、多發性肌炎病患。我們以回溯的方式收集臨床資料，並將病人依據FRAX分數、過去骨鬆骨折、以及骨密度的資料，按照美國風濕病醫學會新的建議，將病人分為高、中、低風險三組。根據新的建議內容以及每個病患於2009年10月至2010年9月期間類固醇用量及時間，我們找出每位病患治療或預防骨鬆的建議藥物。將這些建議藥物和真實處方開立的狀況做比較，並以多變數邏輯式回歸分析其是否遵循建議開立處方的相關因素。結果：在38位病患中，42.1%屬於高風險組，26.3%屬於中風險組，31.6%屬於低風險組。整體來說，在全部38位病患中只有14位（36.8%）病患接受相關的藥物治療或預防。根據建議，89.5%的病患應給予抗骨質吸收劑或是teriparatide來治療或預防類固醇造成的骨鬆症。在高、中、低風險組中，分別有100.0%、100.0%、66.7%的病患應接受藥物治療或預防。在所有建議給予藥物預防或治療類固醇骨鬆症的34位病患中，有13位（38.2%）病患接受藥物來治療或預防骨鬆。而在低、中、高三個風險組中則分別有1位（佔低風險組12.5%）、3位（佔中風險組30.0%）、9位（佔高風險組56.3%）病患接受藥物。多變數邏輯式回歸分析顯示，過去骨鬆骨折和是否遵循建議來給予骨鬆藥物有關（勝算比47.00，95%信賴區間1.07 - 2063.68, p=0.046）。結論：目前老年人的全身紅斑性狼瘡、皮肌炎、多發性肌炎病患因長期使用類固醇所造成的骨質疏鬆症其預防治療現況和現行美國風濕病醫學會2010年建議存在著許多差異，仍待繼續努力。

Objectives: To compare current practice patterns with the American College of Rheumatology (ACR) 2010 recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients over 65 with systemic lupus erythematosus (SLE), polymyositis (PM), or dermatomyositis (DM). Methods: Thirty-eight patients aged above 65 as of October 2009 were included in our study. We retrospectively collected clinical data from electronic medical records and stratified patients into high-, medium-, and low-risk groups based on Fracture Risk Assessment (FRAX) score, history of prior fragility fracture, and bone mineral density, according to the new ACR recommendations. Using the Taiwan version of the FRAX tool, we created a diagram that can serve as a quick reference for corresponding risk stratification in patients in Taiwan receiving corticosteroids. We then identified corresponding treatment choices according to the ACR recommendation and recorded the dose and duration of corticosteroid administration from October 2009 to September 2010. We compared actual prescribing practice to the recommended practice. Multiple variable logistic regression was performed to identify factors that affected adherence to recommendations. Results: Out of 38 patients who fulfilled the inclusion criteria, 31.6% were classified as low risk, 26.3% as medium risk, and 42.1% as high risk. Although pharmacologic interventions for the prevention and treatment of GIOP were recommended for 89.5% overall, and for 66.7%, 100%, and 100% in the low-, medium-, and high-risk groups, respectively, only 14 of the 38 patients (36.8%) in our study received any kind of bisphosphonate or teriparatide to treat or prevent osteoporosis. Specifically, among the 34 patients in our study who met the ACR recommendations to receive pharmacologic interventions, only 13 (38.2%) received antiresorptive medications or teriparatide according to the recommendations, including 1 patient out of 8 (12.5%) in the low-risk group, 3 patients out of 10 (30.0%) in the medium-risk group, and 9 patients out of 16 (56.3%) in the high-risk group. The multivariate logistic regression model showed that past history of osteoporotic fracture was associated with prescription of bisphosphonates or teriparatide (odds ratio = 47.00; 95% confidence interval = 1.07 - 2063.68; p=0.046). Conclusion: Much discrepancy exists between the ACR 2010 recommendations and current practices for prevention and treatment of GIOP in patients over 65 who are diagnosed with SLE, PM, or DM. More efforts against GIOP should be made.