Glucocorticoid‐Induced Osteoporosis
Key Points
Key Points
- Despite increasing treatment options to prevent and treat glucocorticoid-induced osteoporosis (GIOP), many glucocorticoid (GC) -treated patients are not evaluated or treated, resulting in preventable fractures.
- Risk calculators like the Fracture Risk Assessment Tool (FRAX®) underestimate fracture risk for patients on very high doses of GC therapy (e.g., ≥30 mg/day) and do not adequately include frailty, multiple fractures, or fall history.
- This guideline updates the 2017 American College of Rheumatology (ACR) Guideline for GIOP.
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.
Diagnosis
...iagnosi...
...Definitions of Selected Terms Used in the Reco...
...tial Fracture Risk AssessmentFRAX® = Fra...
...2. Fracture Risk Reassessment for Pa...
Treatment
...reatme...
...ommendations for Initial Treatment...
...ations for patients taking prednisone ≥2.5 mg/d...
...children beginning or continuing chronic GC t...
In adults ≥40 years...
...In addition to calcium, vitamin D, and lifestyle...
...or adults ≥40 years with high or very hi...
...years with very high fracture risk, we condi...
...40 years with high fracture risk, we condition...
...r adults ≥40 years with high or v...
...40 years with high or very high fracture...
...40 years with high or very high fracture risk,...
...years with moderate fracture risk, we condition...
...s ≥40 years with low fracture risk, we strongly...
...lts receiving high-dose GC (initial dose ≥30 m...
We conditionally recommend treating with P...
...e strongly recommended over no treatment. (Lo...
...d DEN are conditionally recommende...
...e conditionally recommended in those intoler...
...n adult...
...dition to calcium, vitamin D, and lifesty...
...dults...
Adults
...s with solid organ transplants, glomerular filtrat...
...ludes osteomalacia, adynamic bone di...
...y recommend expert evaluation for CKD-MBD...
...y recommend treatment with oral or IV BP,...
...itionally recommend against using...
...17 years treated with GCs for >3 months (low a...
...y recommend optimization of dietary and...
...tionally recommend against starting oral or IV B...
...s 4-17 years with an osteoporotic fracture wh...
...itionally recommend treating with an oral or...
...al Pharmacological Treatment for Adults...
...gure 4. Treatment Recommendations Whe...
...5. Sequential Osteoporosis Treatment Recommen...