Glucocorticoid-Induced Osteoporosis Management: New Guidelines

Guidelines to foster better risk assessment for bone fracture, and more aggressive strategies for osteoporosis inpatients on glucocorticoid therapy

A panel of experts provided an overview of the American College of Rheumatology draft guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis,1 at the 2016 ACR/AHRP Annual Meeting in Washington, D.C. Still a work in progress, these guidelines will update the 2010 guidelines, said Lenore Buckley, MD, professor of internal medicine and pediatrics at Yale University, during the session.

More aggressive management of fracture risk needed in patients receiving glucocorticoid therapy."To be aware, there is a risk of fracture in people receiving glucocorticoid (GC) treatment and that risk can be decreased with preventive treatment. Physicians must ''look at your patient according to risk and treat accordingly,'' Dr. Buckley told EndocrineWeb.

Glucocorticoids are the preferred treatment for their anti-inflammatory and immunosuppressive properties.2,3  However, their clinical efficacy is limited by long-term metabolic effects that adversely affect many endocrine-related conditions, including osteoporosis, hypertension, dyslipidemia, insulin resistance and type 2 diabetes mellitus.3

While GCs act to reduce the inflammation of autoimmune diseases, they also suppress the body's ability to absorb calcium, so their use is linked to increased risk of osteoporosis and fractures.1,2

Glucocorticoid-Induced Osteoporosis: The Problem

Bone loss is known to be greatest in the first year of GC use, according to Dr. Buckley. About 15% of vertebral fractures and 7.6% of non-vertebral fractures have been linked to use of glucocorticoids.3  The risk factors to assess in each patient are: GC pattern of use, age, sex, and race.1,2 For example, as the length of time a person is on the on the medication and dose rise, so does vertebral fracture risk, not surprisingly. Fracture rates are known to increase quickly after GC are begun and to drop quickly when treatment is terminated, according to Dr. Buckley.

The Draft Guidelines Focus on Patients Over Age 40

The draft guidelines1,2 make these good clinical practice recommendations:

Physicians are advised to conduct a clinical fracture risk assessment for all age groups, said Dr. Buckley, which should include:

  • Medial history, particularly for: GC use, prior falls, frailty, and any other risks related to osteoporosis
  • Physical exam to collect current and historical data on height, weight, muscle strength and spine

The first assessment for osteoporosis should be done within six months of the initiation of treatment and then repeated annually while on treatment

The guidelines add more specific recommendations for adults 40 and over:

  • Repeat the bone mineral density (BMD)
  • Establish a baseline fracture risk assessment tool (FRAX) with bone mineral density (BMD) and GC dose adjustment.
  • 1-3 years for untreated patients; and
  • 2-3 years during treatment, if very high dose GC use or concern for poor adherence/absorption of osteoporosis medicines.
  •  every 2-3 years after completion of treatment

For those under 40 at moderate to high fracture risk, the guidelines state:

  • Baseline BMD
  • Repeat BMD every 2-3 years in all

The guidelines also consider estimated fracture risk for groups based on age, prior fractures and results of the BMD.

Draft Treatment Recommendations

Among the treatment recommendations, Dr. Buckley said, clinicians are advised to increase attention to intake of calcium and vitamin D in patients taking GCs. Adults need 1000-1200 milligrams daily of calcium and 600-800 IUs of Vitamin D daily to start with adjustments for evident deficiency.4

As determined by population intervention comparator outcomes (PICO),5 a methodology that is becoming the preferred tool by professional organizations worldwide, Men, and women who are past childbearing stage, and deemed at moderate to high fracture risk should be treated, in order of preference:

  • Calcium and vitamin D supplementation
  • Lifestyle modification
  • Oral bisphosphonates
  • IV bisphosphonate, for which the recommendation is strong for high-risk patients, but conditional for women at moderate risk
  • Raloxifene (for postmenopausal women when none of the other 4 medicines are appropriate)
  • Teriparatide
  • Denosumab

For special populations, specifically women of childbearing potential at moderate to high risk who are not planning a pregnancy during osteoporosis treatment, solid organ transplant patients, children 4-17 years of age, and very high dose GC treated patients, the draft guidelines include more directed recommendations.

The Guideline Development Process

In a later ACR/AHRP session,5 Timothy McAlindon, MD, MPH, professor and chief of rheumatology at Tufts University School of Medicine, presented a process for developing the evidence base for these draft guidelines. The methodology is known as, GRADE--Grading of Recommendations Assessment, Development and Evaluation, which relies on systemic reviews of medical literature to evaluate evidence in specific domains. This would enhance the process for guide experts on forming recommendations and strength for each.

The draft guidelines included an additional recommendation for how to change treatment decisions over time, Dr. Buckley said. Publication of the final recommendations are expected in early 2017.

Dr. Buckley has no financial conflicts, and Dr. McAlindon reported consulting for the data safety monitoring board on osteoarthritis for Pfizer.

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