Osteoporosis in the home health care setting: A window of opportunity?
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Age Distribution↗
Biomedical subjects
Jeffrey R Curtis
Publications and source records attributed to Jeffrey R Curtis.
Treatment of rheumatoid arthritis.
PURPOSE: Current and investigational treatments of rheumatoid arthritis (RA) are described. SUMMARY: The current therapies used to treat RA include nonsteroidal antiinflammatory drugs (NSAIDs), used for the management of pain and inflammation; disease-modifying antirheumatic drugs (DMARDs), used as first-line therapy for all newly diagnosed cases of RA; and biological-response modifiers, targeted agents that selectively inhibit specific molecules of the immune system. Glucocorticoids and other antirheumatic drugs are also used to treat RA. DMARDs include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide. NSAIDs and glucocorticoids are effective in controlling the pain, inflammation, and stiffness related to RA. Unlike NSAIDs, they slow clinical and radiographic progression of RA. The biological-response modifiers include infliximab, etanercept, and adalimumab (inhibitors of tumor necrosis factor [TNF]-alpha); anakinra, a recombinant inhibitor of interleukin-1; abatacept, the first costimulation blocker; and rituximab, a chimeric anti-CD20 monoclonal antibody. Investigational therapies for RA include anti-interleukin-6-receptor monoclonal antibodies, new TNF-alpha inhibitors (including one for oral administration), and antibodies against proteins critical for B-cell function and survival. Data accumulated in the past decade favor early aggressive therapy for patients suspected of having RA, including early referral to a rheumatologist, new diagnostic techniques, and aggressive therapy with DMARDs, glucocorticoids, and biological agents. The benefits of this approach have been demonstrated in clinical trials. CONCLUSION: Pharmacologic treatments of RA include NSAIDs, glucocorticoids, DMARDs, and biological agents. With an improved understanding of the pathophysiology of RA and the evidence from various clinical trials with the agents, early aggressive therapy with a combination of drugs or biological agents may be warranted for the effective treatment of RA.
Anti-Inflammatory Agents, Non-Steroidal↗
Risks versus benefits of cyclooxygenase-2-selective nonsteroidal antiinflammatory drugs.
PURPOSE: A summary of the basic science underlying the current controversies regarding cyclooxygenase-2 (COX-2)-selective nonsteroidal antiinflammatory drugs (NSAIDs), including data on their cardiovascular safety, their gastrointestinal (GI) benefits, cost-effectiveness, physician-prescribing trends, and recommendations for prescribing these agents is presented. SUMMARY: A number of randomized controlled trials (RCTs) have reported that COX-2-selective NSAIDs increase cardiovascular events, although there appear to be gradations of risks among the COX-2-selective NSAIDs. In addition, traditional NSAIDs may increase the risk for cardiovascular events, complicating the interpretation of RCTs that use traditional NSAIDs as comparators. Selective inhibitors of COX-2-selective NSAIDs are effective antiinflammatory and analgesic drugs with improved upper-GI safety compared to traditional NSAIDs. Data on the cost-effectiveness of COX-2-selective NSAIDs indicate that they should be limited to patients at high risk for upper-GI adverse effects. However, they had been increasingly used in patients with lower GI risks until recent events reversed that trend. Circumstances under which COX-2-selective NSAIDs may be appropriate are in patients at high GI risk and in patients who did not respond to multiple traditional NSAIDs. The national spotlight in the United States on NSAID-related adverse events and recent lawsuits against health care providers prescribing COX-2-selective NSAIDs further highlights the need for provider-patient communication and risk disclosure. The relative cardiovascular risks of NSAIDs are similar in magnitude to other currently prescribed therapies. CONCLUSION: Health care providers must consider the efficacy, GI and cardiovascular risks, concomitant medications, and costs when determining the appropriateness of COX-2-selective NSAID therapy.
Cardiovascular Diseases↗
Population-based assessment of adverse events associated with long-term glucocorticoid use.
OBJECTIVE: The frequency of many adverse events (AEs) associated with low-dose glucocorticoid use is unclear. We sought to determine the prevalence of glucocorticoid-associated AEs in a large US managed care population. METHODS: Using linked administrative and pharmacy claims, adults receiving >or=60 days of glucocorticoids were identified. These individuals were surveyed about glucocorticoid use and symptoms of 8 AEs commonly attributed to glucocorticoid use. RESULTS: Of the 6,517 eligible glucocorticoid users identified, 2,446 (38%) returned the mailed survey. Respondents were 29% men with a mean +/- SD age of 53 +/- 14 years; 79% were white and 13% were African American. Respondents had a mean +/- SD of 7 +/- 3 comorbid conditions and were prescribed a mean +/- SD prednisone-equivalent dosage of 16 +/- 14 mg/day. More than 90% of individuals reported at least 1 AE associated with glucocorticoid use; 55% reported that at least 1 AE was very bothersome. Weight gain was the most common self-reported AE (70% of the individuals), cataracts (15%) and fractures (12%) were among the most serious. After multivariable adjustment, all AEs demonstrated a strong dose-dependent association with cumulative glucocorticoid use. Among users of low-dose therapy (<or=7.5 mg of prednisone per day), increasing duration of use was significantly associated with acne, skin bruising, weight gain, and cataracts. CONCLUSION: The prevalence of 8 commonly attributed self-reported glucocorticoid-associated AEs was significantly associated with cumulative and average glucocorticoid dose in a dose-dependent fashion. Physicians should be vigilant for glucocorticoid-related AEs and should counsel patients about possible risks, even among low-dose long-term users.
Administration, Oral↗
Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system.
OBJECTIVE: To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. METHODS: We examined data from the MEDMARX database, covering the period from January 1, 1999 through December 31, 2003. For allopurinol and colchicine, we examined error severity, source, type, contributing factors, and healthcare personnel involved in errors, and we detailed errors resulting in patient harm. Causes of error and the frequency of other error characteristics were compared for gout medications versus other musculoskeletal treatments using the chi-square statistic. RESULTS: Gout medication errors occurred in 39% (n = 273) of facilities participating in the MEDMARX program. Reported errors were predominantly from the inpatient hospital setting and related to the use of allopurinol (n = 524), followed by colchicine (n = 315), probenecid (n = 50), and sulfinpyrazone (n = 2). Compared to errors involving other musculoskeletal treatments, allopurinol and colchicine errors were more often ascribed to problems with physician prescribing (7% for other therapies versus 23-39% for allopurinol and colchicine, p < 0.0001) and less often due to problems with drug administration or nursing error (50% vs 23-27%, p < 0.0001). CONCLUSION: Our results suggest that inappropriate prescribing practices are characteristic of errors occurring with the use of allopurinol and colchicine. Physician prescribing practices are a potential target for quality improvement interventions in gout care.
Adverse Drug Reaction Reporting Systems↗
Documented tuberculin skin testing among infliximab users following a multi-modal risk communication interventions.
PURPOSE: Following its licensure, tuberculosis (TB) was reported as a potential adverse effect of infliximab. Subsequently, the product circular was changed to recommend tuberculin skin testing before patients received infliximab, which was reinforced by several risk communication efforts. The aim of this study was to evaluate patterns and predictors of documented tuberculin skin testing in patients before and after manufacturer, federal, and academic risk communications. METHODS: Patients administered infliximab were identified from 11 health plans located throughout the United States, and claims data were examined to determine whether the patients had received a tuberculin skin test. Patients were divided into three cohorts depending on the timing of their first infliximab treatment in relation to the risk communication efforts. RESULTS: The overall tuberculin skin testing rate doubled from 15.4% in the first cohort to 30.9% in the last cohort, while the rate of pre-infliximab treatment testing increased from 0 to 27.7% (Chi-squared test for trend, p < 0.0001 for both). Tuberculin skin testing rates were significantly higher in women, those with a diagnosis of rheumatoid or psoriatic arthritis, and those with a rheumatologist as prescriber. After multivariable analysis, only rheumatologist remained significantly associated with tuberculin skin testing. CONCLUSIONS: Although the tuberculin skin testing rate was relatively low overall, tuberculin skin testing doubled over 30 months of ongoing risk communication efforts and under ascertainment likely occurred. We also found variation in the tuberculin skin testing rate associated with physician specialty. This study demonstrates a significant change in patient care following risk communication efforts.
Adult↗
Agreement and validity of pharmacy data versus self-report for use of osteoporosis medications among chronic glucocorticoid users.
PURPOSE: Pharmacy and linked claims databases are commonly used to determine medication receipt as a measure of quality of care. However, these data sources have not been previously compared with self-reported data for receipt of medications used for glucocorticoid-induced osteoporosis (GIOP). METHODS: Using databases from a national managed care organization (MCO), we identified 6282 chronic glucocorticoid users (60+ days in 18 months). We compared self-reported current use of alendronate, risedronate, calcitonin, and raloxifene (reference standard) to different intervals of preceding pharmacy data to determine agreement, sensitivity, specificity, and positive and negative predictive values of the pharmacy data. RESULTS: Survey respondents (n = 2363) were mean +/- SD age 53 +/- 14 years old, 70% women, and 78% Caucasian. Agreement between self-reported and pharmacy data ranged from Kappa = 0.64 (95%CI 0.53-0.75) (calcitonin) to 0.80 (0.76-0.84) (alendronate). The positive predictive value of a filled prescription in the pharmacy database in the prior 6 months exceeded 90% compared to the reference standard of self-reported current bisphosphonate use. However, the 6-month interval of pharmacy data failed to capture >25% of self-reported current bisphosphonate users. The optimal interval of pharmacy data to distinguish between current and past bisphosphonate users was 120-180 days. CONCLUSIONS: Among chronic glucocorticoid users enrolled in managed care, underreporting of current osteoporosis medication use was uncommon, and agreement between self-report and pharmacy data was high. Use of pharmacy data alone is unlikely to underestimate quality of osteoporosis care, but different intervals of pharmacy data have important implications on the ability to identify current users of osteoporosis medications.
Alendronate↗
Ethnic variations in the prevalence of metabolic bone disease among HIV-positive patients with lipodystrophy.
A high prevalence of metabolic bone disease and osteonecrosis among HIV+ patients on highly active antiretroviral therapy (HAART) has been reported in predominantly white cohorts. We examined bone health in an ethnically diverse cohort of 23 African-Americans and 21 non-African-Americans who were mean (standard deviation) age 45 (7) years old, 66% male, and on HAART for 34 (28) months. Non-African-Americans were more likely to have osteopenia or osteoporosis (59%) compared to African-Americans (26%) (p = 0.09). The prevalence of vitamin D insufficiency (< 34 ng/ml) and elevated i-PTH (>65 pg/ml) was 79% and 20%, respectively. Higher mean urinary N-telopeptide levels were found in non-African-Americans [58 (34) nmol BCE/mmol] compared to African-Americans [41 (18) nmol BCE/mmol] (p = 0.09). Magnetic resonance imaging identified one African-American subject (3%) with bilateral asymptomatic hip osteonecrosis. Our findings suggest that the burden of metabolic bone disease in HIV+ patients with HAART-associated lipodystrophy may be greater in whites than in African-Americans. Studies to examine ethnic variations in bone metabolism are necessary to devise optimal interventions.
Absorptiometry, Photon↗
Trends in prevention of glucocorticoid-induced osteoporosis.
OBJECTIVE: To determine longitudinal patterns and predictors for the utilization of bone mass measurements and anti-osteoporotic medications in the prevention of glucocorticoid-induced osteoporosis. METHODS: Within a managed care population of 7 million persons, we identified 3,125 adult men and women who had initiated longterm glucocorticoid therapy (>or=7.5 mg/day of prednisone equivalent for > 6 mo). The study population was examined by 3 biennial intervals between years 1996 and 2001 for receipt of a bone mass measurement and use of anti-osteoporotic medication (bisphosphonate, calcitonin, raloxifene, hormone replacement therapy). RESULTS: Receipt of a bone mass measurement increased among postmenopausal women from 10% in 1996-97 to 19% in 2000-01, but remained below 6% in all biennial intervals among women under age 50 and men. The use of anti-osteoporotic medication was most common among postmenopausal women, where it approached 50%. The largest absolute increase in anti-osteoporotic medication utilization was among women ages 65 and over, increasing from 24% in 1996-97 to 44% in 2000-01. The specialty of physician providing care was associated with receipt of both testing and treatment. Odds of receipt of a bone mass measurement and anti-osteoporotic medication were 3 to 4 times greater among patients of rheumatologists compared to those of internists or family practitioners. CONCLUSION: Among patients initiating longterm glucocorticoid therapy, the proportion of individuals receiving a bone mass measurement or anti-osteoporotic medication remains relatively low, but has improved temporally among postmenopausal women.
Adolescent↗
Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients.
OBJECTIVE: To evaluate patient and physician factors associated with prevention of glucocorticoid-induced osteoporosis and to describe temporal trends in screening and prevention of glucocorticoid-induced osteoporosis. METHODS: Using databases from a national managed care organization, enrollees who had been prescribed glucocorticoids (taken for at least 60 days) during an 18-month period were identified. Administrative data from January 2001 through June 2003 and linked survey data from October 2003 were examined for measurement of bone mass, prescription of antiresorptive medication, and use of over-the-counter calcium and/or vitamin D treatment. Factors associated with screening and bone-protective therapies were identified using multivariable logistic regression, focusing on physician specialty and survey respondent ethnicity. Trends in glucocorticoid-induced osteoporosis prevention were assessed using administrative data from 2001-2003 versus 1995-1998. RESULTS: We identified 6,281 patients who were prescribed glucocorticoids in 2001-2003 (mean +/- SD prescribed prednisone-equivalent dosage 16 +/- 14 mg/day). Forty-two percent underwent bone mass measurement and/or were prescribed bone-protective medication; rates were lowest for men (25%). Compared with patients of internists, the odds of bone mass measurement were lowest among patients prescribed glucocorticoids by family physicians (odds ratio [OR] 0.56 [95% confidence interval] [95% CI] 0.30-1.04) and highest among patients prescribed glucocorticoids by rheumatologists (OR 1.48 [95% CI 1.06-2.08]). Patients prescribed glucocorticoids by gastroenterologists were less likely to be treated with antiresorptive agents (OR 0.49 [95% CI 0.28-0.86]). African American patients were less likely than white patients to be screened (OR 0.55 [95% CI 0.40-0.75]) or treated (OR 0.71 [95% CI 0.51-0.98]). The frequency of bone mass measurement among glucocorticoid-treated patients in 2001-2003 increased 3-fold compared with 1995-1998, and the use of prescription antiresorptive medication increased approximately 2-fold. CONCLUSION: Despite significant temporal increases in the frequency of screening for and treatment of glucocorticoid-induced osteoporosis, absolute rates remain low, especially among men, African Americans, and patients of certain physician specialties.
Adult↗
A group randomized trial to improve safe use of nonsteroidal anti-inflammatory drugs.
OBJECTIVE: To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs). STUDY DESIGN: Controlled, cluster-randomized trial. METHODS: Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering. RESULTS: Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention. CONCLUSIONS: Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests.
Adult↗
Swallowing difficulties from "DISH-phagia".
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Aged↗