Treatment/prophylaxis of corticosteroid induced osteoporosis in adults

Corticosteroid induced osteoporosis in adults:

• oral corticosteroids increase the risk of spine and hip fractures, even at doses of less than 7.5 mg of prednisolone per day (1)
  • treatment for prevention of osteoporosis is recommended if:
    • a person is starting oral corticosteroids and is likely to be on these for a duration of at least 3 months;
    • if a person has been taking oral corticosteroids for the last 3 months and is aged over 65 years;
    • or if a person has a past history of a previous fragility fracture
  • if a person is aged less than 65 years and has no history of fragility fracture, but is likely to remain on corticosteroids for at least 3 months, then s/he should have his/her bone mineral density (BMD) measured using dual-energy X-ray absorptiometry (DXA) scanning (1)
    • osteoporosis prophylaxis is recommended if the T-score is -1.5 or less - this is because oral corticosteroid treatment leads to an increased risk of fracture over and above the effect of a low BMD (i.e. for a given BMD, there is a higher fracture risk in corticosteroid-induced osteoporosis than in postmenopausal osteoporosis)
      
      
• lifestyle measures are advised for patients at risk of corticosteroid induced osteoporosis
  
  • adequate dietary intake of calcium and vitamin D
  • regular exercise - various exercise measures including
    • low-impact, weight-bearing exercise e.g. walking
    • high-intensity strength training - targeting of the muscle groups around the hips, spine, and wrists
  • smoking cessation
  • avoidance of excessive alcohol intake
    
    
• pharmacological treatment
  • daily calcium (1-1.2g) and vitamin D (800iu) supplements are indicated, particularly in individuals who have a poor intake such as the elderly, housebound or institutionalised. This supplementation however is generally regarded as an adjunct
  • therapy with an oral bisphosphonate represents the main form of therapy. Bisphosphonates should not be given to women of child bearing capacity unless specialist advice has been sought. Bisphosphonates are incorporated into the skeleton and the potential effects on future pregnancies are unknown. In the event of intolerance or contraindication to bisphosphonate therapy, specialist advice should also be sought
    • SIGN suggest with respect to options for bisphosphonate theray (5):
    • alendronic acid may be considered to prevent vertebral fractures in men and women on prednisolone doses of 7.5 mg daily or greater (or an equivalent dose of glucocorticoids) for three months or more
    • risedronate should be considered to prevent vertebral fracture in men and women on prednisolone doses of 7.5 mg daily or greater (or an equivalent dose of glucocorticoids) for three months or more
    • zoledronic acid should be considered to prevent vertebral fracture in men and women on prednisolone doses of 7.5 mg daily or greater (or an equivalent dose of glucocorticoids) for three months or more. The treatment should be considered in patients who are intolerant of oral bisphosphonates and those in whom adherence to oral therapy may be difficult
      
      

Notes:

• more than three or four courses of corticosteroids taken in the previous 12 months is considered to be equivalent to more than 3 months of continuous treatment
  • if the intermittent courses of corticosteroid treatment are spread over a much longer term, then this is not regarded as such an important risk factor (1)

Reference:

• 1. Royal College of Physicians of London (2002) Glucocorticoid-induced osteoporosis. Royal College of Physicians.
• 2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60250-6/abstractReid DM et al. Zoledronic acid and risedronate in the prevention and treatment of glucocorticoid-induced osteoporosis (HORIZON): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet 2009; 373(9671): 1253-1263.
• 3. MHRA (2005) Latest data on HRT from the UK Million Women Study. Medicines and Healthcare products Regulatory Agency
• 4. Campbell IA et al. Five year study of etidronate and/or calcium as prevention and treatment for osteoporosis and fractures in patients with asthma receiving long term oral and/or inhaled glucocorticoids. Thorax 2004;59(9): 761-768
• 5. SIGN (June 2020). Management of osteoporosis and the prevention of fragility fractures.