New guidelines for steroid-induced osteoporosis

Dr Jean-Pierre Devogelaer and colleagues in the Belgian Bone Club report a set of evidence-based guidelines for the prevention and treatment of glucocorticoid (GC)-induced osteoporosis in Osteoporosis International The guidelines largely validate what has been standard practice for many clinicians but carry a heightened warning about the risk of osteoporosis associated with even low doses of glucocorticoids.

“There is no safe GC dose. Bone-mineral density [BMD] should be checked soon after start of GC therapy. Effective preventive therapy for osteoporosis exists!” Devogelaer tells rheumawire.Treatment, BMD monitoring recommended with GC useThe guidelines recommend that physicians treating patients on GCs:- Give all patients taking GCs supplemental calcium and vitamin D. – Urge them to exercise regularly and to avoid tobacco and alcohol. – Consider hormone-replacement therapy in young postmenopausal females as well as in postmenopausal women and in men with low androgen levels. – Add calcitonin or bisphosphonates in cases of long-term GC use.”These recommendations are not frankly different from the former ones, but they are necessary because preventive therapy is still too infrequently prescribed in prevention of GC osteoporosis,” Devogelaer says. He notes that all patients on GCs are threatened with osteoporosis and that prevention and/or therapy should be considered for osteopenic premenopausal females and for males on a daily dose equivalent to 7.5 mg/day or more of prednisolone, as well as for postmenopausal women. The authors write, “Supplemental calcium and vitamin D should be considered as the first-line therapy because of the decrease in intestinal calcium absorption provoked by GCs. They also could be considered either as isolated therapy in patients taking less than 7.5 mg prednisolone daily and/or for a predicted period shorter than three months or as adjuvant therapy to other more potent drugs.”The guidelines recommend maintaining therapy as long as the patient is taking GCs but note that it might be stopped after weaning from GCs because there is evidence that BMD recovers when GCs are stopped. The analysis did not demonstrate any benefit from combining two antiresorptive agents or one antiresorptive agent plus an anabolic agent. Several questions remain about the optimal agents and schedule for preventing GC-related bone loss. Devogelaer pointed to the need for prospective studies to determine the appropriate duration of bisphosphonate therapy. (Source: Devogelaer JP, Goemaere S, Boonen S, et al. Evidence-based guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int2005; DOI: 10.1007/s00198-005-2032-z. Joint and Bone: Rheumawire: november 2005.)