Glucocorticoid‐Induced Osteoporosis

Publication Date: October 16, 2023

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

  1. 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.
  2. 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.
  3. All adult patients >18 years of age with medium, high, or very high fracture risk should be offered osteoporosis (OP) therapy.
  4. Oral bisphosphonates (BP) are strongly recommended over no treatment in high or very high fracture risk adults.
  5. 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]).
  6. 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.
  7. 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.
  8. 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

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Treatment

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