Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care?

S. Sapkota, S. Baig, T. Hess, A. M. O’Connell, J. Menk, M. Shyne, P. Fazeli, K. Ensrud, A. Shmagel

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


OBJECTIVE: This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard.

METHODS: We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription.

RESULTS: A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care ( p  = 0.098).

CONCLUSIONS: In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.

Original languageEnglish (US)
Pages (from-to)263-272
Number of pages10
Issue number3
StatePublished - Mar 1 2020

Bibliographical note

Publisher Copyright:
© The Author(s) 2020.


  • Fracture Risk Assessment score
  • Glucocorticoids
  • SLE
  • bisphosphonates
  • glucocorticoid-induced osteoporosis
  • vitamin D
  • Vitamins/therapeutic use
  • Humans
  • Middle Aged
  • Male
  • Bone Density Conservation Agents/therapeutic use
  • Prednisone/adverse effects
  • Young Adult
  • Adult
  • Female
  • Retrospective Studies
  • Osteoporotic Fractures/epidemiology
  • Risk Factors
  • Minnesota/epidemiology
  • Glucocorticoids/adverse effects
  • Diphosphonates/therapeutic use
  • Lupus Erythematosus, Systemic/drug therapy
  • Rheumatology/methods
  • Osteoporosis/chemically induced
  • Vitamin D/therapeutic use

PubMed: MeSH publication types

  • Journal Article


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