Bone Abstracts

The ECTS and IOF have recently constructed a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for three months or longer. These review the epidemiology of GIO; assessment of risk utilises a fracture probability-based approach and intervention thresholds are based on 10 year probabilities using FRAX. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

Oral glucocorticoids are prescribed for a wide variety of medical disorders, most commonly musculoskeletal disease and obstructive pulmonary disease. Up to 4.6% of postmenopausal women are reported as currently taking oral glucocorticoids, and fracture risk increases during the first three to six months of glucocorticoid therapy. An increase in fracture risk occurs with low doses and rises further with increasing daily dose; the greatest increase in risk is seen for vertebral fracture where patients taking prednisolone >7.5 mg daily have a relative risk of 5.18 (95% CI 4.25–6.31).

The management of GIO in premenopausal women and men is complicated by a dearth of evidence addressing the epidemiology, risk assessment, and therapeutic interventions. Premenopausal women and younger men have a lower risk of fracture than older individuals, although there is evidence that glucocorticoid-treated premenopausal women fracture at higher BMD than their postmenopausal counterparts. Data on the effects of pharmacological interventions in this population are sparse, particularly with regard to fracture risk. In large, randomised, controlled trials in which subsets of premenopausal women and men were studied, therapy with alendronate, risedronate and etidronate has been reported to prevent bone loss at the lumbar spine when compared to placebo. In the comparative study of zoledronic acid versus risedronate, a subset analysis of men in the trial demonstrated significantly greatly increases in lumbar spine BMD at one year among men treated with zoledronic acid. Teriparatide has been shown to result in larger increases in BMD than alendronate in premenopausal women and men with GIO.

Despite the lack of evidence for fracture reduction in glucocorticoid-treated premenopausal women and younger men, bone protective therapy may be appropriate in some cases, particularly among patients treated with high doses of glucocorticoids and in those with a previous history of fracture. The long term use of bisphosphonates and the potential for side effects remains a concern; caution is advised to women of child bearing age as bisphosphonates cross the placenta and may affect the skeletal health of the developing fetus.