Study Of Factors Associated With Bone Turnover In Patients On Glucocorticoid Therapy In Dermatology

Objective: To demonstrate the risk factors of glucocorticoid-induced bone loss and their relative significance in dermatology patients, investigate the prophylaxis situation of glucocorticoid-induced osteoporosis, and further evaluate the clinical effects on bone loss of prophylaxis pathway for glucocorticoid-induced osteoporosis in dermatology department.Methods:(1) The medical records of 63 cases patients in Sir Run Run Shaw Hospital of Zhejiang University from January 2004 to April 2007 were reviewed, and the correlations of patients' gender, age, glucocorticoid accumulative dose and therapy duration et al with patients' BMD were analyzed by using multiple liner regression analysis and Bivariate correlation analysis.(2) 73 cases of systemic lupus erythematosus and anaphylactoid purpura inpatients' clinical data from January 2004 to March 2006 in dermatology department were reviewed. Patients requiring treatment with at least 10mg/d doses of prednisone (or equivalent) for more than 3 months were included in this retrospective study. The outputs of BMD investigation and the monitoring and prophylaxis situation of glucocorticoid-induced osteoporosis were investigated.(3) From May 2006, all inpatients receiving glucocorticoid therapy for more than 3 months or prospected for more than 3 months had their baseline bone mineral density (BMD) investigated after hospitalization, and data regarding the use of glucocorticoid, osteoporosis prophylaxis and monitoring were also collected and compared with the retrospective data.A prospective self-control clinical trial was conducted to study the effect of alendronate in treating patients with decreased BMD after administration for 3 and 6 months.Result:(1) Risk factors of glucocorticoid-induced bone loss were as follows: Multiple liner regression analysis and Bivariate correlate analysis showed that among patients who received glucocorticoid therapy less than 12 months, the ages and accumulative glucocorticoid doses were negatively correlated to patients' BMD of lumber spine, Pearson correlation coefficients were -0.39, -0.53, p<0.05, respectively, and BMD of lumber spine also had liner regression relationship with patients' age, glucocorticoid accumulative dose, the unstandardized coefficients was -0.01, 0.00, and standardized coefficients was -0.50, -0.62, p<0.01, respectively. Among patients who received glucocorticoid therapy for more than 12 months, the BMD of lumber spine was negatively correlated to the accumulative glucocorticoid dose within the latest half and one years before BMD investigation, Spearman correlation coefficients were -0.58, -0.42, p<0.05, respectively, meanwhile, BMD at lumber spine also had liner regression relationship with patients' glucocorticoid accumulative dose within 12 months, supplement of calcium plus Vitamin D and age, the unstandardized coefficients was -0.000, 0.001, 0.006, and standardized coefficients was -0.59, 0.47, 0.39, p<0.05, respectively. The BMD of neck was negatively correlated to glucocorticoid duration, Spearman correlation coefficient was -0.39, p<0.05. The present study also showed that patients who received calcium in combination with vitamin D had higher BMD compared with no supplement or single calciumsupplement, p<0.05, but no significant difference between different calcium and vitamin D doses; patients with decreased BMD had higher level of serum calcium and albumin than patients with normal BMD, p<0.05. No significant differences of lumber spine and neck BMD were seen between SLE patients and non-SLE patients, p>0. 05.(2) The investigating results about monitoring and prophylaxis situation of glucocorticoid-induced osteoporosis showed that 31.50% Of 73 patients received BMD investigation. 50% patients who received assessment showed reduced baseline BMD at lumbar spine before glucocorticoid therapy. 84.62% who received BMD investigation 6 months after glucocorticoid administration showed reduced BMD at lumbar spine. Of 73 patients who qualified for osteoporosis prophylaxis in the retrospective study, 39.72% patients did not receive any osteoporosis prophylaxis, 49.31% had received calcium in combination with vitamin D, 22.7% had received bisphosphonate as primary prophylaxis. Only 2 (16.67%) of 12 cases with decreased BMD had received bisphosphonate as secondary prophylaxis. It suggested a high incidence of glucocorticoid-induced osteoporosis and a low prophylaxis and monitoring rate of this complication.(3) After implementation of prophylaxis pathway, 63.41% of 41 patients received BMD investigation. 57.89% who received assessment showed reduced baseline BMD at lumbar spine, 15.79% were osteoporosis. 57.14% cases who received BMD investigation 6 months after glucocorticoid administration showed reduced BMD at lumbar spine and 42.86% were osteoporosis. Of 41 patients, 97.56% had received calcium in combination with vitamin D, 4.88% had received bisphosphonate as primary prophylaxis. 12 (57.14%) of 21 cases with decreased BMD had received bisphosphonate as secondary prophylaxis. The prospective self-control clinical trial among inpatients and outpatients showed that no significant differences of BMD were seen after 3 months' therapy of alendronate at lumber spine and neck. Marked increase in BMD of lumber spine (4.1%) compared with baseline data were seen after 6 months, p<0.05. It suggested the effect of alendronate in treating glucocorticoid-induced bone loss at lumber spine.Conclusions:(1) Among patients on glucocorticoid therapy less than one year, age and accumulative glucocorticoid dose were negatively correlated to patients' BMD at lumber spine, and the effect of accumulative dose was larger than age;(2) Among patients on glucocorticoid therapy more than one years, lumber spine BMD was negative correlated to the glucocorticoid doses within recent 6&12 months;(3) Patients' neck BMD was only negatively correlated to glucocorticoid therapy duration;(4) Supplement of calcium and vitamin D with dose less than recommended was already helpful for maintaining BMD in patients' lumber spine, especially in patients on glucocorticoid therapy more than 12 months;(5) The incidence of glucocorticoid-induced bone loss was high, and prophylaxis situation was serious. The monitoring measures and prescriptions of prophylaxis therapy for osteoporosis in patients treated with steroids are much lower than that has been recommended , implementation of prophylaxis pathway for glucocorticoid-induced osteoporosis significantly elevated the monitoring and prophylaxis level of osteoporosis in dermatology patients on glucocorticoid therapy.(6) As secondary prophylaxis, 6-month alendronate administration was effective in treating glucocorticoid-induced bone loss at lumber spine.