Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis
Publication Date: October 16, 2023
Last Updated: December 19, 2023
Key Recommendations
- As soon as possible after initiation of ≥2.5 mg/day GC treatment for >3 months, screening for fracture risk in patients ≥40 years of age should be assessed by using FRAX® and by performing bone mineral density (BMD) using dual-energy x-ray absorptiometry (DXA) with vertebral fracture assessment (VFA) testing or spinal x-rays. BMD with VFA testing or spinal x-ray is advised in patients <40 years, as FRAX® is not validated in this population.
- Adequate age-appropriate dietary and supplemental intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake is encouraged for all patients receiving GCs.
- All adult patients >18 years of age with medium, high, or very high fracture risk should be offered osteoporosis (OP) therapy.
- Oral bisphosphonates (BP) are strongly recommended over no treatment in high or very high fracture risk adults.
- For adults >18 years of age with very high fracture risk, anabolic agents (parathyroid hormone [PTH] and PTH-related protein [PTHrP]) are conditionally recommended over antiresorptive agents (BP or denosumab [DEN]).
- In adults ≥40 years of age at high risk of fracture, DEN or PTH or PTH or PTH or PTH/ PTHrP are conditionally recommended over BP.
- In adults >18 years of age at moderate risk of fracture, oral or intravenous (IV) BP, DEN, and PTH and PTH and PTH and PTH/PTHrP are conditionally recommended.
- Include in decision-making that sequential OP treatment is recommended to prevent rebound bone loss and vertebral fractures after discontinuation of DEN, romosozumab, and PTH and PTH and PTH and PTH/PTHrP.
Treatment
Table 3. Recommendations for Initial Treatment for Prevention of GIOP in Adults Beginning Long-term GC Therapy
Recommendations for patients taking prednisone ≥2.5 mg/day for >3 months
For adults and children beginning or continuing chronic GC treatment at low, moderate, high, or very high risk of fracture, we conditionally recommend optimizing dietary and supplemental calcium and vitamin D in addition to lifestyle modifications. (Low-quality evidence, Conditional recommendation)
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In adults ≥40 yearsa
a In addition to calcium, vitamin D, and lifestyle modifications.
For adults ≥40 years with high or very high fracture risk, we strongly recommend OP therapy over no treatment. Agents to use include oral BP,b IV BP,c PTH PTH / PTHrP,c DEN,c RAL, or ROM. (Low-quality evidence, Strong recommendation)
b Strong recommendation based on fracture data.
c Conditional due to a lack of fracture data.
c Conditional due to a lack of fracture data.
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For adults ≥40 years with very high fracture risk, we conditionally recommend PTH recommend PTH / PTHrP over anti-resorptive (DEN, BP) treatment. (Low-quality evidence, Conditional recommendation)
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For adults ≥40 years with high fracture risk, we conditionally recommend PTH recommend PTH recommend PTH recommend PTH/PTHrP or DEN over BP treatment. (Low-quality evidence, Conditional recommendation)
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For adults ≥40 years with high or very high fracture risk, we strongly recommend oral BP over no treatment. (Low-quality evidence, Strong recommendation)
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For adults ≥40 years with high or very high fracture risk, we conditionally recommend using ROM or RAL in patients intolerant of other agents. (Very low-quality evidence, Conditional recommendation)
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For adults ≥40 years with high or very high fracture risk, we conditionally recommend against using two different OP medications together. (Very low-quality evidence, Conditional recommendation)
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For adults ≥40 years with moderate fracture risk, we conditionally recommend against ROM except for in patients intolerant of other agents, due to risk of myocardial infarction, stroke, or death. (Very low-quality evidence, Conditional recommendation)
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For adults ≥40 years with low fracture risk, we strongly recommend against OP medications due to known risk of harms and no evidence of benefit. (Low-quality evidence, Strong recommendation)
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Adults receiving high-dose GC (initial dose ≥30 mg/day for >30 days or cumulative dose ≥5 g in 1 year)
We conditionally recommend treating with PTH recommend treating with PTH / PTHrP over anti-resorptives. (Low-quality evidence, Conditional recommendation)
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Oral BP are strongly recommended over no treatment. (Low-quality evidence, Strong recommendation)
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IV BP and DEN are conditionally recommended over no treatment. (Low-quality evidence, Conditional recommendation)
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RAL and ROM are conditionally recommended in those intolerant of other agents. (Low-quality evidence, Conditional recommendation)
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In adults <40 yearsa
a In addition to calcium, vitamin D, and lifestyle modifications.
Adults <40 years with moderate fracture risk, we conditionally recommend oral or IV BP,d DEN,d or PTH or PTH / PTHrP therapy. (Low-quality evidence, Conditional recommendation)
b Strong recommendation based on fracture data.
d Only for patients who are not planning on pregnancy during the OP treatment period or are using effective birth control if sexually active.
d Only for patients who are not planning on pregnancy during the OP treatment period or are using effective birth control if sexually active.
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Adults <40 years with moderate fracture risk, we conditionally recommend against using ROM due to risk of myocardial infarction, stroke, or death. (Very low-quality evidence, Conditional recommendation)
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For adults with solid organ transplants, glomerular filtration rate ≥35 mL/min, and no evidence of chronic kidney disease–mineral and bone disorder (CKD-MBD)e or hyperparathyroidism
e Includes osteomalacia, adynamic bone disease, osteitis fibrosa cystica, mixed uremic osteodystrophy.
We conditionally recommend expert evaluation for CKD-MBD in renal transplant recipients. (Low-quality evidence, Conditional recommendation)
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We conditionally recommend treatment with oral or IV BP, DEN, PTH PTH / PTHrP, or RAL based on individual patient factors. (Low-quality evidence, Conditional recommendation)
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We conditionally recommend against using ROM due to risk of myocardial infarction, stroke, or death. (Very low-quality evidence, Conditional recommendation)
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Children ages 4–17 years treated with GCs for >3 months (low and moderate risk)
We conditionally recommend optimization of dietary and supplementation of calcium and vitamin D as recommended by the US Recommended Dietary Allowances (RDA) depending on the age of the child. (Very low-quality evidence, Conditional recommendation)
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We conditionally recommend against starting oral or IV BP due to low risk of OP fractures in this age group. (Very low-quality evidence, Conditional recommendation)
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Children ages 4-17 years with an osteoporotic fracture who are continuing treatment with GCs at a dose of ≥0.1 mg/kg/day for >3 months (high risk)
We conditionally recommend treating with an oral or IV BP. (Very low-quality evidence, Conditional recommendation)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis
Authoring Organization
American College of Rheumatology
Publication Month/Year
October 16, 2023
Last Updated Month/Year
March 19, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To develop recommendations for prevention and treatment of glucocorticoid‐induced osteoporosis (GIOP).
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Prevention
Diseases/Conditions (MeSH)
D010024 - Osteoporosis, D005938 - Glucocorticoids
Keywords
glucocorticoids, glucocorticoid‐induced osteoporosis, GIOP
Source Citation
Humphrey MB, Russell L, Danila ML, et al. 2022 American College of Rheumatology Clinical Practice Guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheumatol. 2023 Oct 16. doi: 10.1002/art.42646. Online ahead of print. Arthritis Care Res. doi: 10.1002/acr.25240.