Timing of Systemic Glucocorticoid Administration Increases Repeat Fracture Risk

Hi, I'm Justin David. I'm a three-year med student at LSU in New Orleans and I'm presenting my project, Timing of Systemic glucocorticoid Administration Increases Repeat fracture Risk.

Osteoporosis can be a very debilitating condition and, um, patients with osteoporosis due to their increased risk of fragility fractures. And if they have one fragility Fracture, it increases their risk of a Repeat fracture.

There are many different factors that can increase the risk of fractures, including lifestyle factors such as smoking and alcohol, Medical conditions such as um neurological disorders, and then certain medications can increase the risk as well. And one of those medications is glucocorticoids, and those have been shown to decrease bone mineral density by up-regulating osteoclasts and down-regulating osteoblasts.

Now, because there are medications that have been shown to decrease bone mineral density and increased risk of fractures, there have been some studies that look at the association to see if patients who are on these medications before a Fracture get taken off these medications after. And what the studies have shown is there's really no change in the prescriptions given out. Um, if they're on the medication before the Fracture, they're more likely to be taking that medication after the Fracture as well.

So what we wanted to do is explore the trends of systemic glucocorticoid use before and after their Primary Fracture and to see if there's an association with repeat fractures.

So our cohort consisted of 2,643 patients in the Research Action for Health Network database or known as the ReENET database. And all these patients had a non-traumatic Fracture diagnosis code with at least 1 year of medical history prior to the Fracture and 2 years of follow-up time after the Fracture.

So the Primary variables we studied were the timing of administration, which was before or after the Fracture, and then the method of administration, which was oral or parenteral. And in our case, parenteral steroids includes intravenous, intramuscular, and intra-articular just because it was difficult to distinguish um the method of administration based on ICD codes. So then we also looked at different demographic factors, lifestyle factors, and history of Other medication used to see their association as well.

Our cohort consisted of mostly non-Hispanic Caucasian patients with public insurance who are older than 70 years old, and most of them had a diagnosis of osteoporosis already. Out of the 2,643 patients, 20.6% of them had a Repeat fracture within our time window of two years.

Um, and then out of all these factors that we studied, the only things that were significantly associated with an increased risk of repeat fractures was a diagnosis of osteoporosis and use of corticosteroids.

We found that steroid users were more likely to be African American, have private insurance, have a BMI above 30, smoke tobacco, or be prescribed bisphosphonates.

42% of the cohort received glucocorticoids within the time frame, which was one year prior to the Fracture and then 2 years after the Fracture. 17% received a steroid before their initial Fracture and then 36% received a steroid after their initial Fracture. In addition, the rate of glucocorticoid use is increasing over time from 23.8% in 2011 to 50% of the cohort in 2015.

And if the patient is using glucocorticoids before their Fracture, their odds of use after the Fracture is 4.1, 4.51 times higher than patients without steroid use.

So when we looked at the timing of steroid administration, we found that steroid use after the initial Fracture shouldn't uh significantly increased odds of Repeat fracture, but the use before the initial Fracture or both before and after was not significant.

When we looked at administration method, we found that parenteral steroids was associated with a significantly increased odds of Repeat fracture, but oral steroids trended towards an increased risk but was not statistically significant. Then when we looked at uh method of administration and timing together, the only combination associated with increased repeat fractures was parenteral use after the initial Fracture.

And so you can see that in this chart here. Top part shows the method of administration. If the horizontal line does not cover the midline, that means it's statistically significant. So, oral steroids trended towards the right but overlapped that line a little bit. So it's not statistically significant while intravenous or parentheral steroids was significantly associated. Then the next section down shows the timing of steroids and the only

Um, combination that increased Repeat fracture risk with steroids after the Fracture. And then when we looked at administration and timing together, the only combination was parenteral steroids after the Fracture, which increased the risk for repeat fractures.

So glucocorticoid use is very prevalent in this cohort of patients at risk for fragility fractures, which was 42% of the patients receiving a steroid and its use is increasing over time. So we found that parenteral steroids, but not oral steroids are associated with an increased odds of fragility Fracture. And this could

Potentially be explained by parenteral steroids being more potent and having a higher dose response, um, than the oral steroids or maybe patients receiving parenteral steroids, uh, may be sicker and like maybe they cannot physically um take oral steroids or maybe they're already in the hospital with Other, um, comorbidities, and these comorbidities can increase the risk of fractures as well.

Um, and we know that some patients may need steroids for certain conditions where the benefits outweigh the risks of an increased fragility risk. So we compiled a list of medical

Conditions such as COPD exacerbations, autoimmune disorders, allergic disorders where steroid use is required. And we found that only about 50% of the patients who received the steroid had a diagnosis within 7 days that required steroid use, which shows that there are still many patients who are on steroids who do not need to be.

And therefore, they're increasing their risk of fragility fractures. So, it may be important for physicians going forward to make sure to review a patient's medication list, make sure they're on uh medicines only if they need to be, and watch out for glucocorticoid use in these patients if they've had a history of a Fracture, especially if it's parenteral steroids after the Fracture. Thank you.