On September 14, 2022, the American College of Rheumatology (ACR) released a summary of Updated guidelines (PDF) on how to manage glucocorticoid-induced osteoporosis (GIOP), a condition that can occur in people who take steroids as part of their treatment. The full manuscript is expected to be released in 2023.
The update comes five years after the 2017 ACR recommendations and includes information on the newer osteoporosis treatments, Tymlos (abaloparatide) and Evenity (romosozumab), as well as recommendations for sequential therapy to prevent rebound fractures.
Steroids relieve symptoms and treat many conditions, but they may increase the risk of osteoporosis
Glucocorticoids (GCs) can reduce inflammation and pain common in rheumatic diseases such as Rheumatoid arthritis (RA) In addition to other chronic conditions, including multiple sclerosis (MS), Crohn’s disease, and ulcerative colitis (University of California), psoriasis, skin diseaseAllergies, asthma and heart failure.
Related: 8 great pain relievers you don’t use
Although GCs are a valuable tool, treatment guidelines usually emphasize the need to use steroids sparingly due to safety concerns and potential side effects. In cases where long-term treatment or the use of steroids in higher doses, the risk of osteoporosis becomes a concern.
Long-term use of steroids weakens the bones and increases the chance of fracture
“An excess of glucocorticoids harms bone mineral density and bone quality resulting in an increased risk of fracture,” he says. Catherine Wiesham, MD, assistant professor of rheumatology at UW School of Medicine in Seattle. That’s because steroids tend to reduce the body’s ability to absorb calcium, while at the same time increasing the speed at which bone is broken down.
How Much Long-Term Steroid Use – And Risky?
Oral steroids at a dose equal to or greater than 5 mg of prednisone per day taken for longer than three months are considered to have a fracture risk, and the risk increases with increasing daily dose of steroids, according to New York State Osteoporosis Prevention and Education Program (NYSOPEP). Bone loss occurs most rapidly in the first six months after starting oral steroids; After 12 months of chronic steroid use, there is slower bone loss, according to the NYSOPEP Center.
Compared to oral steroids, inhaled steroids are less likely to cause bone loss.
Steroids that are used for only a few days or applied topically in the form of a cream or ointment are not associated with bone loss.
It is estimated that fractures occur in up to 50 percent of long-term steroid users, according to A study published in Endocrinology and Metabolism Clinics in North America. Even doses as low as 2.5 mg of prednisolone per day may increase the risk of fracture Research.
It is recommended that fracture risk be evaluated immediately upon initiation of steroid therapy
Once steroid therapy is started, fracture risk should be assessed as soon as possible, at least within six months after initiation, and annually thereafter, for each Article published in 2021 in open access rheumatology. Other risk factors can include:
- History of falls or fractures
- Low body weight or malnutrition
- alcohol use
People with risk factors for osteoporosis (in addition to using glucocorticoid therapy) should be considered for stronger antiperspirant or anabolic treatments to reduce fracture risk, and sequential treatment may be necessary, he says. Bart Clark, MDan endocrinologist and professor of medicine at the Mayo Clinic in Rochester, Minnesota.
Fracture risk decreases when steroids are stopped
The good news is that once you stop taking steroids, your fracture risk drops quickly, according to Posted in The New England Journal of Medicine.
Great retrospective exhibition A study published in International Osteoporosis Organization They showed an increased risk of a significant osteoporotic fracture among people who had taken anabolic steroids for longer than three months within the past year, but not among people who had used steroids intermittently or previously (more than a year prior).
What is sequential therapy?
Sequential treatment begins with one drug, then moves to another drug after a while. The sequence allows for greater bone density than treatment with just one drug and helps maintain gains in bone mass and bone strength.
How Preventing and treating steroid-induced bone loss
If you have rheumatoid arthritis, Crohn’s disease, eczema, or one or more of the countless conditions that can be managed with steroids, you’ll need to understand how to reduce your risk of bone loss and fractures.
Sequential therapy can reduce fracture risk in people with GCOP
Tymlos (abaloparatide) and Evenity (romusuzumab) were welcome additions to treatment options for people with osteoporosis, says Dr. Wiesham. She says these are anabolic treatments that build new bone, improve bone density, and help prevent fracture. Antiperspirant medications prevent bone loss and may increase bone density.
Dr. Clark says these two new treatments for osteoporosis reduce fracture risk more than previously available treatments, have a quick onset and compensate for the work. Forteo (teriparatide), an osteoporosis medication approved in 2002, also works by building bone.
He says that using bisphosphonates after stopping anabolic agents can prevent the rapid bone loss that would otherwise occur, and the attendant increased fracture risk.
In some cases, Prolia (denosumab) may be used for bone loss after patients have completed a course of Tymlos or Evenity.
Sequential treatment is also recommended when using Prolia (denosumab) and Forteo (teriparatide), which are also associated with loss of BMD and increased fracture risk after discontinuation.
“By emphasizing sequential treatment, the GIOP Guidelines update highlights the importance of defining a treatment course for each patient that includes an exit strategy for any drug that requires additional treatment upon discontinuation,” says Wysham.
Updated guidelines encourage joint decision making between provider and patient
The new guidelines reflect the reality of clinical care for patients with osteoporosis, Clark says. “More clinical trial data has become available over the past five years to help guide clinical treatment. Studies show that some drugs work better than others, and that one drug is sometimes not enough. While new drugs are more effective, they are also more effective than others. It still works best with sequential treatment.
“Rather than thinking about the best drug for each fracture risk category, the updated GIOP guidelines emphasize joint decision-making between the patient and the prescribing practitioner. This supports the individualization of treatment options, which is good for patient care,” says Wysham.