Patients who suffer from chronic inflammatory conditions such as rheumatoid arthritis, asthma, or inflammatory bowel disease often take prednisone or other glucocorticoids over long periods of time. One of the most serious side effects of this treatment is glucocorticoid-induced osteoporosis (GIOP), with half of chronic glucocorticoid users developing bone loss that leads to fracture.
Despite much that has been written about his issue, much remains unsettled, notes Kenneth G. Saag, M.D., M.Sc., of the University of Alabama at Birmingham, in a recent review of the topic. There is controversy over whether a safe glucocorticoid dose exists and whether the peak or cumulative dose is most strongly associated with bone loss.
Most guidelines suggest a bone mass density test if the patient will receive treatment with greater than 7.5 mg or more of prednisone or its equivalent per day for at least 1 to 6 months. Several specialty societies have released recommendations that advocate an aggressive approach to GIOP based on accumulating evidence of the efficacy of several anti-osteoporosis medications, particularly the amino-bisphosphonates (for example, etidronate and risedronate). Some physicians prescribe a bisphosponate immediately for patients at high risk of bone loss (those on more than 20 mg/day of prednisone or equivalent for 3 months or more, postmenopausal women, and those at high risk for a fall), while others wait.
Vitamin D and calcium also may help prevent GIOP. Thiazide diuretics, which have substantial side effects, may decrease urinary calcium excretion and be particularly helpful during the early phase of glucocorticoid use, when this excretion is profound. Estrogen and testosterone supplements may help offset gonadal deficiency, bisphosphonates and calcitonin may prevent bone resorption, and fluoride and parathyroid hormone could stimulate osteoblastic bone formation.
Dr. Saag's work is supported in part by the Agency for Heathcare Research and Quality Centers for Education and Research on Therapeutics (CERTs) program (HS10389). Ongoing CERTs projects are examining ways to improve care for glucocorticoid-induced osteoporosis.
See "Glucocorticoid-induced osteoporosis," by Dr. Saag, in Endocrinology and Metabolism Clinics of North America 32, pp. 135-157, 2003.