Systemic lupus erythematosus patients and tertiary specialist care - simple considerations dropping through the cracks: Osteoporosis monitoring as an example

M. Hew, E. J. McKinnon, B. Kirwin, O. P. Martinez, Michaela Lucas

Research output: Contribution to journalLetterpeer-review

Abstract

We read with interest the paper by Nikpour et al. 1 noting the lack of Australian epidemiological data for lupus treatment. As lupus and its treatments directly impact on osteo-porosis, we expect that tertiary lupus specialists be actively aware of this common comorbidity and their patients' routine bone monitoring investigations fol-lowed, whether these are conducted in hospital or exter-nally by general practitioners. We recently reviewed rates of osteoporosis monitoring in a tertiary hospital cohort of well-defined systemic lupus erythematosus patients under non-endocrinological specialist care, identifying significant gaps in practice in this at-risk group. The monitoring aspects were presence of documented bone densitometry (DXA) and biochemical markers of bone turnover to determine the level of active awareness of this co-morbidity in our patient cohort. Between 2002 and 2010, 2325 positive anti-dsDNA antibody tests were performed by the state public pathol-ogy provider in Western Australia. Removing serial results on the same patient, and patients not seen in the tertiary hospital system, we identified 271 potential sub-jects, for whom 190 medical records were available for review. This confirmed 103 subjects had systemic lupus erythematosus and ongoing tertiary hospital care. Paedi-atric patients, patients not seen at least four times in the tertiary clinics and patients with discoid lupus, drug-induced lupus, rheumatoid arthritis, overlap syndrome or inflammatory bowel disease were excluded. Our population was mostly female (87.4%) with a median age of 44 years (interquartile range 34.5–55.5 years) and rheumatological (82%), cutaneous (79%), bone marrow (56%), renal (51%) or serosal (29%) disease manifestations. This cohort was cared for by immunology and/or rheumatology (87%), with renal medicine (33%) or other specialities (dermatology, haematology, neurology) in 12% of patients overall. Overall, 30% of patients were under the care of more than one treating team. A single DXA was performed in 27% of subjects, and more than once in 37% with no difference in frequency between males and females. A comparison of the per-centage of patients with multiple serum measures, as opposed to a single measurement, of calcium (71% vs 88%), vitamin D (47% vs 63%), parathyroid hormone (18% vs 37%) and fasting metabolic bone studies (14% vs 23%) suggests that monitoring over time for these indices may also be lacking. The relative frequency of serial DXA scans correlated positively with the duration of prednisolone treatment (normalised to time under observation since 2002) (Spearman's R = 0.51, P textless 0.0001) indicating that awareness of glucocorticoid-induced osteoporosis may at least be present. If tradi-tional risk factors for osteoporosis were documented, then we noted a correlation with ordering of all moni-toring tests at least once (R = 0.23, P = 0.03) or serially (R = 0.32, P = 0.003); however, patients were not more regularly monitored if under shared care compared with being under a single non-endocrinological speciality (P = 0.9). As the purpose of this audit was evaluation of tertiary hospital care, there is potential bias in patient selection, which may not reflect care provided outside of the hospital setting; however, as an indicator of non-endocrinological specialist awareness and management of a co-morbidity associated with active lupus, it indicates management we can improve on in Western Australia.
Original languageEnglish
Pages (from-to)596
Number of pages1
JournalInternal Medicine Journal
Volume45
Issue number5
DOIs
Publication statusPublished - 2015

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