Preventing steroid harms in people with polymyalgia rheumatica in English primary care – assessing the effect of prophylactic medications on fragility fractures and gastro-intestinal adverse events

Problem

Polymyalgia rheumatica (PMR) causes pain, stiffness and disability in older adults. It usually has a sub-acute onset and responds rapidly to treatment with steroids, although the initial improvement is typically followed by longer periods of lower-level symptoms and episodes of relapse. Steroid use is associated with increased risk of fractures and gastrointestinal (GI) bleeding. Mitigating steroid adverse effects is a key clinical and patient research priority. Pharmacological strategies to reduce the risk of adverse events exist, but research suggests the prescription of prophylactic medication is low. We do not know what factors affect this, nor the implications on incidence of fractures or GI adverse effects. We describe how medicines other than steroids are used in the management of people with PMR in England primary care and the impact of this on fractures and GI adverse events.

Approach

Using data from Clinical Practice Research Datalink we identified a population of people aged ≥50, diagnosed with PMR between January 2010 and March 2022, and prescribed prednisolone within 21 days of their first PMR consultation. Stage 1: Medications were characterised as prevalent (before PMR diagnosis), incident (at the time of diagnosis), or late (after diagnosis, but whilst still on steroids ) use. We considered age, gender, and deprivation; and stratified by risk factors associated with fractures and GI bleeds. Stage 2: We used a target trial approach to assess the effect of bisphosphonates and gastro-protective medications on fractures and GI bleeds.

Findings

Stage 1: 43,091 people were included. Users of oral bisphosphonates were 5.9% prevalent, 35.8% incident, and 25.5% late. Users of gastroprotection were 34.7% prevalent, 29.9% incident, and 14.0% late. Users of analgesia were 26.5% prevalent, 14.3% incident, and 15.4% late. 32.5% of people who had other risk factors for fracture were not prescribed bisphosphonates and 19% of people with additional risk factors for GI adverse events were not prescribed gastroprotection once treated with steroids. 45% were prescribed opioids either before diagnosis or during their disease course. There was variation in prescribing by gender and socioeconomic group. Stage 2: Results will be available by the time of the meeting.

Consequences

Many people with PMR who are at higher risk of adverse events from their steroid treatment do not receive prophylactic medication. There is variation in prescribing of analgesia and prophylactic medication by gender and levels of socioeconomic deprivation. This suggests that practice could be improved. The target trial analysis will produce estimates of the change in risk associated with prophylactic medication in this population, which will inform better shared decision making.