Key Points
- It is estimated that 1% of the US population is treated long-term with glucocorticoids (GC). However, GC use causes significant toxicity, including bone loss and fractures. More than 10% of patients who receive long-term GC treatment are diagnosed with a fracture, and 30–40% have radiographic evidence of vertebral fractures.
- The highest rate of bone loss occurs within the first 3–6 months of GC treatment, and a slower decline continues with persistent use.
- Both high daily and high cumulative GC doses increase risk of fracture, particularly vertebral fracture, due to the greater effects of GCs on trabecular bone than on cortical bone.
- In children, GC treatment also affects bone strength, growth, and total adult skeletal mass, with a similar profile of risk factors.
- If GC treatment is terminated, bone mineral density (BMD) increases and fracture risk declines.
- In addition, the absolute risk of future fracture in an individual is substantially influenced by demographic and other characteristics (age, race, sex, and concomitant osteoporosis [OP] risk factors).
- It is important to identify those patients taking GCs for whom the benefits of preventive therapy sufficiently outweigh potential harms.
Diagnosis
Table 1. Fracture Risk Categories in GC-Treated Patients
Adults ≥40 years of age | Adults <40 years of age | |
|---|---|---|
High fracture risk |
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Moderate fracture risk |
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Low fracture risk |
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a https//www.shef.ac.uk/FRAX/tool.jsp. b Increase the risk generated with FRAX by 1.15 for major osteoporotic fracture and 1.2 for hip fracture if GC treatment is >7.5 mg/day (e.g., if hip fracture risk is 2.0%, increase to 2.4%). c Major osteoporotic fracture includes fractures of the spine (clinical), hip, wrist or humerus. | ||
Figure 1. Initial Fracture Risk Assessment
Figure 2. Reassessment of Fracture Risk
