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...
...finitions of Selected Terms Used in t...
...ial Fracture Risk AssessmentFRAX® = Fracture...
...ure Risk Reassessment for Patients Continuing Chro...
Treatment
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Figure 3. Initial Pharmacological Treatment for...
...ent Recommendations When New Fracture...
...5. Sequential Osteoporosis Treatment Re...