This week the American College of Rheumatology updated its 2010 guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis.
The guidelines are based on the findings of a systematic review that focused on the benefits and harms of glucocorticoid-induced osteoporosis. They include recommendations for the initial assessment and reassessment of patients beginning or continuing long-term glucocorticoid treatment, and the use of calcium, vitamin D, bisphosphonate, raloxifene, teriparatide and denosumab treatment for adults who are on long-term glucocorticoid treatment plans.
Osteoporosis is a concern for patients who take glucocorticoids long-term, which accounts for 1% of all Americans. Of these, 10% will have a fracture and 30–40% will have radiographic evidence of vertebral fractures, so the risk of adverse effects is very real and they usually occur rather quickly within the first three to six months of treatment.
Although there is little scientific evidence on the benefits and harms of the long-term use of glucocorticoids, treatment guidance is needed because few patients receive preventative treatment.
"Despite increasing information about risk factors for fracture in glucocorticoid users and the availability of effective therapies to prevent fracture, many long-term glucocorticoid users never receive therapy to prevent bone loss or are treated only after a fracture has occurred," wrote Lenore Buckley, M.D., MPH, of Yale University, and colleagues in the June 6 issue of Arthritis and Rheumatology.
Patients at greatest risk of fractures include those with low bone strength at the beginning of treatment and those who exhibit a greater rate of decline in bone mass during treatment. But the damage can be reversible. Evidence has shown that bone mineral density increases and fracture risk declines after the treatment stops. Risk calculators can be helpful in determining a patient’s risk of these fractures.
The recommendations cover:
- Treating only with calcium and vitamin D in adults at low fracture risk.
- Treating with calcium and vitamin D plus an additional osteoporosis medication (oral bisphosphonate preferred) in adults at moderate-to-high fracture risk.
- Continuing calcium plus vitamin D but switching from an oral bisphosphonate to another anti-fracture medication in adults in whom oral bisphosphonate treatment is not appropriate.
- Continuing oral bisphosphonate treatment or switching to another antifracture medication in adults who complete a planned oral bisphosphonate regimen but continue to receive glucocorticoids.
- Recommendations for special populations, including children, people with organ transplants, women of childbearing potential, and people receiving very high-dose glucocorticoids.
In this slideshow, we highlight the recommendations.