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 Interest
Dr Banh and Ms Chan have no conflicts
to declare
 Dr Cave has received research support
from GSK, Astra-Zeneca, Novartis. Merck
Canada, Grifols, Boeringer-Ingelheim but
has no conflict related to this study

Introduction

Inhaled 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 Prevention

Calcium 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
Objectives

Primary: 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
Number of patients who received appropriate
or pending BMD follow up vs. inappropriate
BMD follow up
100
90
Number of patients
80
70
60
Inappropriate
50
Appropriate or pending
40
30
20
10
0
> or = 65 years old
< 65 years old
Results Summary


Subjects are more than twice as likely to
take appropriate vitamin D than calcium
Taking 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
Discussion

Study 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.
Acknowledgements
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Costco #544 – Sherwood Park, Alberta
Shoppers Drug Mart #302 – Edmonton, Alberta
Shoppers Drug Mart #312 – Edmonton, Alberta
Shoppers Drug Mart #346 – Edmonton, Alberta
Shoppers Drug Mart #386 – Edmonton, Alberta
Shoppers Drug Mart #2301 – Edmonton, Alberta
London Drugs #22 – Edmonton, Alberta
Safeway Capilano – Edmonton, Alberta
Sprucewood Pharmacy – Lloydminster, Alberta
Walmart #3118 – Edmonton, Alberta
Walmart #1570 – Camrose, Alberta
Walmart #7236 – Edmonton, Alberta
Questions?