Common Questions
What is appropriate monitoring and treatment of patients on systemic corticosteroids?
Once patients are planning to begin oral corticosteroid therapy for at least 3 months, or if they have already been on this therapy, their risk for osteoporosis needs to be determined. The most significant bone loss occurs in the first three to six months of corticosteroid therapy, so prevention of corticosteroid-induced bone loss should be emphasized.
The National Osteoporosis Society (NOS) and the American College of Rheumatology (ACR) have developed treatment guidelines to help prevent corticosteroid-induced osteoporosis (1,2). The NOS recommendations are as follows: If the patient is less than 65 years old and has no history of a fragility fracture, obtain a baseline DXA scan of the hip and spine. Treatment recommendations are based on the T score.
| T score | Treatment |
|---|---|
| T score above 0 | Lowest possible dose of corticosteroids and possibly steroid-sparing therapy |
| Good nutrition with at least 1000mg calcium and 400 IU vitamin D daily | |
| Regular weight-bearing exercise | |
| Avoid tobacco use and alcohol abuse | |
| T score between 0 and -1.5 | All measures discussed above |
| Repeat BMD in 1-3 year if glucocorticoids continued | |
| T score equal to or less than -1.5 | All measures discussed above for T score above 0 |
| Depending on age and fracture probability, consider treatment with bisphosphonate as first-line agent, calcitonin as second-line agent | |
| Repeat BMD in 6 months to 1 year |
The ACR guidelines differ from the NOS guidelines in that bisphosphonates are recommended in any patient beginning >3 month corticosteroid (>5 mg prednisone/day) therapy, except with extreme caution in pre-menopausal women. A DXA scan is not required prior to treatment. For patients who have been receiving long term (>6 months) corticosteroid therapy, the ACR recommends treatment with a bisphosphonate or calcitonin if the T score is below -1.0. If the BMD is normal, repeat the DXA in 1 year.
Patients older than 65 or who have had a fragility fracture are at high risk for a fracture. Both the NOS and ACR recommend medical therapy with a bisphosphonate (first-line) or calcitonin (second-line), in addition to the lifestyle measures discussed above, calcium and vitamin D supplementation, and BMD monitoring every 6 months to 1 year. BMD measurement is not required prior to initiating therapy. For those with a previous fragility fracture, secondary causes of osteoporosis should be excluded.
If patients have greater than 5% decline in BMD on follow-up DXA scans, additional work-up and/or treatment may be necessary (1). Ensure patients are compliant with the recommendations discussed above. If so, consider testing for additional secondary causes of osteoporosis. Consider switching a patient to a bisphosphonate if they are taking calcitonin. The addition of calcitonin has not been shown to significantly improve BMD in a patient taking a bisphosphonate (1). After therapy has been continued for two years and the BMD has stabilized, follow-up DXA scans may be obtained as needed clinically.
- National Osteoporosis Society. Guidelines on glucocorticoid-induced osteoporosis. 2002. Available online.
- American College of Rheumatology. Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis and Rheumatism 2001; 44;7: 1496-1503.
- Yeap SS, Hosking DJ. Management of corticosteroid-induced osteoporosis.. Rheumatology 2002; 41: 1088-1094.