How to Manage Steroid-Induced Osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) is a common problem, and the consequences can be catastrophic, especially in an aging population, and in patients with rheumatic disease.

Lenore Buckley, MD, MPH, and Mary Humphrey, MD, PhD, published a nice review of GIOP in the New England Journal of Medicine, highlighting the patients at risk, the consequences, treatments (including calcium, vitamin D, bisphosphonates, anabolic and biologic therapies), guidelines, and recommendations.

Key takeaways from the review include:

• Risk factors for glucocorticoid-induced fractures include age (age >55), female sex, white race, and long-term use of prednisone at a dose of >7.5 mg per day.
• Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. The risk of fracture among patients who are ages ≥40 can be estimated with the use of bone mineral density (BMD) testing and the fracture risk assessment tool (FRAX).
• Patients who receive glucocorticoids should be counseled about adequate intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake.
• Pharmacologic treatment is strongly recommended for anyone who has had a fracture, and for patients who are at least age 40 if, according to FRAX, the risk of major osteoporotic fracture is ≥20%, or the risk of hip fracture is at least 3%.
• Pharmacologic treatment is also recommended for men who are ages ≥50, and for postmenopausal women, who are on glucocorticoids and have a BMD T score of −2.5 or less (indicating osteoporosis) at either the spine or the femoral neck.
• Bisphosphonates are recommended as first-line treatment of osteoporosis because of their low cost and safety.
• The risk of fracture decreases rapidly when glucocorticoids are discontinued. Exposure to glucocorticoids should be minimized as much as possible.

In light of these recommendations, here’s a case study: a woman, age 75, with polymyalgia rheumatica is on prednisone, at a dose of 20 mg daily with a plan to taper the dose to 5 mg daily within 6 months. She is slated to be on drug for 2 years. Her serum 25-hydroxyvitamin D level is 30 ng/ml (74 nmol/L). Her BMD T score is −1.2 at the femoral neck.

How would you advise to prevent GIOP and fracture in this patient?

Jack Cush, MD, is the director of clinical rheumatology at the Baylor Research Institute and a professor of medicine and rheumatology at Baylor University Medical Center in Dallas. He is the executive editor of RheumNow.com. A version of this article first appeared on RheumNow, a news, information and commentary site dedicated to the field of rheumatology. Register to receive their free rheumatology newsletter.