Prevention and Treatment of Osteoporosis in Long-term Glucocorticoid Users

Desiree Lie, MD, MSEd

Disclosures

August 19, 2002

Question

What are the treatment guidelines to prevent or treat osteoporosis in women on long-term oral glucocorticoids?

Response from Desiree Lie, MD, MSEd

The guidelines for prevention and treatment of osteoporosis for steroid-induced bone loss are similar to those for other causes of osteoporosis. The primary goals are to minimize the dose of glucocorticoids; diagnose, assess, and reduce bone loss; and increase bone density. The major recommendations come from the American College of Rheumatology (ACR).[1,2] General fracture prevention recommendations include exercise, smoking cessation, and fall prevention.

The following specific strategies for reducing bone loss in patients on chronic glucocorticoid regimens are supported by current evidence:

  • Vitamin D and calcium supplementation. Calcium supplementation of 1000 to 1500 mg/day prevents bone loss as measured by dual energy X ray absorptiometry (DEXA) densitometry at the lumbar spine and hip, and also increases total body calcium in patients on long-term high-dose inhaled glucocorticoids for asthma and in patients on oral glucocorticoids for rheumatoid arthritis.[3,4] In patients with rheumatoid arthritis receiving low-dose glucocorticoid therapy (mean of 5.6 mg/day), the addition of vitamin D at 400 to 800 IU/day to calcium resulted in increased bone density in the lumbar spine and trochanter, compared with those on placebo who lost bone.[5]

  • Estrogen replacement therapy. There is literature to support the efficacy of estrogen in preventing glucocorticoid-induced bone loss.[6,7] Literature on postmenopausal osteoporosis supports the use of estrogen to prevent fractures, and is well summarized by the North American Menopause Society (www.nams.org) and the National Osteoporosis Foundation.[8] However, 2 recent studies on the cardiovascular risks of hormone replacement urged a review of benefit and risk assessment in women.[9,10] In premenopausal women on chronic glucocorticoids, the ACR recommends the use of an estrogen-containing oral contraceptive for women with menstrual irregularities, who are at even higher risk of osteoporosis.[1]

  • Bisphosphonates. Alendronate has been shown to be efficacious for increasing bone density at the lumbar spine, trochanter, and femoral neck at doses of 5 mg or 10 mg daily, compared with placebo treatment.[11,12] A mean reduction in vertebral fractures from 3.7% to 2.3% over 2 years was associated with these findings. Risedronate, another bisphosphonate, has been shown to have similar effects, with data showing that use increased bone density at the lumbar spine and femoral neck and reduced vertebral fracture risk by 70%.[13,14]

  • Cessation of glucocorticoid use. Bone mineral density has been shown to increase 6 months after cessation of long-term glucocorticoids.[15] But patients who suffered bone fracture while receiving glucocorticoids may see less benefit from cessation.

In summary, for patients using prednisone at a level of 5 mg/day or higher for 3 months or more, the ACR recommendations for prevention and treatment of osteoporosis include:

  • Calcium and vitamin D supplementation at 1500 mg and 800 IU/day respectively;

  • Bisphosphonate therapy (alendronate 10 mg/day or risedronate 5 mg/day);

  • Estrogen replacement for postmenopausal women (if not contraindicated);

  • Estrogen-containing oral contraceptives (if not contraindicated) for premenopausal women with menstrual irregularities; and

  • Consideration of use of inhaled calcitonin at 200 IU/day if bisphosphonates are contraindicated, or if there is fracture or bone pain.[1,2]

The ACR also recommends annual bone densitometry and 24-hour urinary calcium excretion measurements (for hypercalciuria) for patients who are receiving long-term glucocorticoid treatment. Whenever possible, discontinuation of glucocorticoid therapy should be considered to reverse bone loss.

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