Prevention and treatment of glucocorticoid-induced osteoporosis
- Harold N Rosen, MD
Harold N Rosen, MD
- Assistant Professor in Medicine
- Harvard Medical School
- Kenneth G Saag, MD, MSc
Kenneth G Saag, MD, MSc
- Professor of Medicine
- University of Alabama at Birmingham
Glucocorticoid therapy is associated with an appreciable risk of bone loss, which is most pronounced in the first few months of use. In addition, glucocorticoids increase fracture risk, and fractures occur at higher bone mineral density (BMD) values than occur in postmenopausal osteoporosis. The increased risk of fracture has been reported with doses of prednisone or its equivalent as low as 2.5 to 7.5 mg daily . Thus, glucocorticoid-induced bone loss should be treated aggressively, particularly in those already at high risk for fracture (older, prior fragility fracture). In other individuals, clinical risk factor and bone density assessment may help guide therapy. The prevention and treatment of glucocorticoid-induced bone loss will be reviewed here. The clinical features are reviewed separately. (See "Pathogenesis, clinical features, and evaluation of glucocorticoid-induced osteoporosis".)
Many of the prevention and treatment strategies for glucocorticoid-induced bone loss are similar to those used to prevent and treat other causes of osteoporosis. (See "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men" and "Evaluation and treatment of premenopausal osteoporosis".)
Prevention and treatment strategies consist of attempts to reverse the glucocorticoid excess by decreasing the dose of exogenous glucocorticoid or curing the cause of endogenous cortisol overproduction, calcium and vitamin D supplementation, and in some patients, pharmacologic therapy to minimize further bone loss or reverse it. In an attempt to minimize bone loss, certain general principles should be followed in all patients receiving all doses of glucocorticoids for a duration of ≥3 months [2,3].
●The glucocorticoid dose and the duration of therapy should be as low as possible, because even what are thought to be replacement doses or chronic inhaled glucocorticoids can cause bone loss . Alternative therapy should be used whenever possible. (See "Major side effects of inhaled glucocorticoids", section on 'Osteoporosis'.)
●When glucocorticoids are given, topical therapy (such as inhaled glucocorticoids or glucocorticoid enemas for asthma or bowel disease, respectively) is preferred over enteral or parenteral glucocorticoids, whenever possible.
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- GENERAL MEASURES
- CALCIUM AND VITAMIN D
- Active vitamin D metabolites
- CANDIDATES FOR PHARMACOLOGIC THERAPY
- Osteoporosis prevention
- Established osteoporosis
- Premenopausal women and younger men
- CHOICE OF THERAPY
- Zoledronic acid
- Other bisphosphonates
- Bisphosphonates versus active D metabolites
- PARATHYROID HORMONE
- HORMONE REPLACEMENT
- Effect of cessation of glucocorticoid therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS