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
...iagnosis
...ble 2. Definitions of Selected Terms Used in...
...al Fracture Risk AssessmentFRAX®...
...re 2. Fracture Risk Reassessment for Patients Con...
Treatment
Treatm...
...mendations for Initial Treatment for Prevention...
...ecommendations for patients taking predniso...
...or adults and children beginning or...
...adults ≥40 yea...
...tion to calcium, vitamin D, and lifest...
...≥40 years with high or very high f...
For adults ≥40 years with very high f...
...r adults ≥40 years with high fracture...
For adults ≥40 years with high or very...
...adults ≥40 years with high or very high fractu...
...r adults ≥40 years with high or very...
...40 years with moderate fracture risk, w...
...40 years with low fracture risk, w...
...g high-dose GC (initial dose ≥30 mg/day for...
...ditionally recommend treating with PTH rec...
...BP are strongly recommended over no treatment. (...
...BP and DEN are conditionally recommended...
...ROM are conditionally recommended in thos...
In adul...
...n to calcium, vitamin D, and lifesty...
...dults
Adult...
For adults with solid organ transpla...
...osteomalacia, adynamic bone disease, osteitis fib...
We conditionally recommend expert ev...
We conditionally recommend treatment wi...
...nditionally recommend against using ROM due to r...
...hildren ages 4–17 years treated with GCs f...
...ally recommend optimization of dietary an...
...nally recommend against starting oral or IV...
...17 years with an osteoporotic fracture who are c...
...ly recommend treating with an oral or IV BP....
...Initial Pharmacological Treatment for Adults...
...ure 4. Treatment Recommendations Whe...
.... Sequential Osteoporosis Treatment...