ACR guideline recommends customized approach for prevention of glucocorticoid-induced osteoporosis

To prevent glucocorticoid-induced osteoporosis in patients being treated for inflammatory conditions, physicians should consider calcium and vitamin D for adults at low fracture risk and an additional osteoporosis medication in adults with moderate to high risk, according to new recommendations by the American College of Rheumatology (ACR).

The guideline addresses initial assessment and reassessment in patients beginning or continuing long-term glucocorticoid treatment for three months or more, as well as the relative benefits and harms of lifestyle modification and of calcium, vitamin D, bisphosphonate, raloxifene, teriparatide, and denosumab in the general adult population.

The guideline appeared June 6 in Arthritis & Rheumatology, and Arthritis Care & Research.

Because of limited evidence regarding the benefits and harms of interventions in glucocorticoid users, most recommendations are conditional (uncertain balance between benefits and harms). Recommendations include:

• 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 antifracture medication in adults in whom oral bisphosphonate treatment is not appropriate, and
• continuing oral bisphosphonate treatment or switching to another antifracture medication in adults who complete a planned oral bisphosphonate regimen but continue to receive glucocorticoid treatment.

Clinicians and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities, and these recommendations should not be used to limit or deny access to therapies, according to the guideline.

An initial clinical fracture risk assessment should be performed as soon as possible, but at least within six months of starting long-term glucocorticoid treatment, the guideline said. The assessment should include a history with the dose, duration, and pattern of glucocorticoid use; an evaluation for falls, fractures, frailty, and other risk factors for fracture; and a physical examination including measurement of weight and height (without shoes), testing of muscle strength, and assessment for other clinical findings of undiagnosed fracture as appropriate for the patient's age.

In addition, for adults 40 years of age or older, the initial absolute fracture risk should be estimated using FRAX with adjustment for glucocorticoid dose and done mass density as soon as possible but at least within six months of starting glucocorticoid treatment. For these patients, bone mass density testing should be done as soon as possible but at least within six months of starting glucocorticoid treatment if patients are at high fracture risk because of a history of previous osteoporosis fractures or have other significant osteoporosis risk factors.

Optimizing intake of calcium (1,000 to 1,200 mg/d) and vitamin D (600 to 800 IU/d; serum level ≥20 ng/mL), as well as lifestyle modifications (eating a balanced diet, maintaining weight in the recommended range, stopping smoking, performing regular weight bearing or resistance training exercise, limiting alcohol intake to one to two alcoholic beverages per day) are conditionally recommended for all patients receiving glucocorticoid treatment.

For patients in whom oral bisphosphonates are not appropriate, IV bisphosphonates should be used rather than no additional treatment beyond calcium and vitamin D.

If bisphosphonate treatment is not appropriate, teriparatide should be used rather than no additional treatment beyond calcium and vitamin D. Also, if neither oral nor IV bisphosphonates nor teriparatide treatment is appropriate, denosumab should be used rather than no additional treatment beyond calcium and vitamin D.