The American College of Rheumatology (ACR) has released an update Guideline that advises treatment providers on when and for how long to prescribe treatments that prevent or treat glucocorticoid-induced osteoporosis (GIOP). Since the ACR last updated the guidelines in 2017, the Food and Drug Administration has approved new treatments for osteoporosis, which are now included in the recommendations.
The new guidelines also advise doctors that they may need to transfer patients to a second treatment after completing the first course — so-called sequential therapy — to better protect them from bone loss and fractures. It also provides detailed instructions on what medications to use and when and for how long to take these medications for patients who have been taking glucocorticoids over a long period of time.
Including a sequential treatment guideline is important and will be beneficial for practicing physicians, according to SB Tanner IV, MD, director of the Osteoporosis Clinic at Vanderbilt Health, Nashville, Tennessee.
“For the first time, the ACR has provided guidelines for starting and stopping treatment,” Tanner said. “This guideline supports the awareness that osteoporosis is lifelong – something that will constantly need to be monitored.”
An estimated 2.5 million Americans use glucocorticoids, according to a 2013 study in Arthritis Care and Research. Meanwhile, a 2019 resident study in Denmark It was found that 3% of people in the country were prescribed glucocorticoids annually. That study estimated that 54% of glucocorticoid users were female and found that the percentage of people taking glucocorticoids increased with age.
Glucocorticoids are used to treat a variety of inflammatory conditions, from multiple sclerosis Lupus, it is often prescribed to transplant patients to prevent their immune system from rejecting new organs. When you take these medications over time, you can Cause osteoporosisWhich in turn increases the risk of fracture.
more than 10% of patients Those receiving long-term treatment with glucocorticoids are diagnosed with clinical fractures. In addition, even Low-dose glucocorticoid therapy It is associated with an average bone loss of 10% per patient per year.
After stopping some GIOP preventative treatments, there is still a significant risk of bone loss or fracture, according to Linda Russell, MD, director of the Osteoporosis and Health Metabolism Center for the Hospital for Special Surgery, New York City, and co-director and investigator on the new evidence.
“We wanted to make sure that the need for sequential therapy was appropriately communicated, including to patients who may not know they need to start a second medication,” Russell said.
Physicians and patients should be aware that upon completion of a course of GIOP treatment, another medication for the condition should be started, as specified in the guideline.
“Early intervention can prevent glucocorticoid-induced fractures that can lead to significant morbidity and increased mortality,” said Mary Beth Humphrey, MD, PhD, interim vice president for research at the University of Oklahoma Health Sciences Center in Oklahoma City. From the ACR Guidelines.
Janet Rubin, MD, vice chair of research in the Department of Medicine at the University of North Carolina at Chapel Hill, said she hopes the guideline will change practice. They have been known since the beginning of time, but the evidence reinforces the risks and treatment strategies of rheumatologists.” “Such recommendations are known to influence a doctor’s prescribing habits.”
Anyone can be broken
While age and other risk factors including menopauseIncreased risk of GIOP, rapid bone loss can occur in a patient of any age.
Even a glucocorticoid dose as low as 2.5 mg will increase the risk of vertebral fractures, with some occurring as early as 3 months after starting treatment, Humphrey said. For patients taking up to 7.5 mg per day, the risk vertebral fracture my husband. Doses of more than 10 mg per day for more than 3 months increase the likelihood of a vertebral fracture by 14 times, and lead to a 300% increase in the likelihood of a hip fracture, according to Humphrey.
“When taking steroids, even patients with very high degrees of bone density can break,” Tanner said. “The 2017 guideline was almost too detailed in its efforts to calculate risks. The updated guideline recognizes moderate risk and indicates that this is a group of patients who need treatment.”
Arrangement adds flexibility
The updated ACR guidelines also no longer categorize drugs based on patient fracture data, side effects, cost care, and whether the drug is provided through injection, pill, or IV.
Humphrey said that all preventive treatments recommended by the committee reduce the risk of steroid-induced bone loss.
“We thought the 2017 guidance was too restrictive,” Russell said. “We give clinicians and patients more space to choose medication based on their preferences.”
A patient’s preference for the delivery mechanism–such as the desire to take only pills–can now be more balanced in drug treatment decisions.
“In the exam room, there are three dynamics going on: what the patient wants, what the doctor knows is most effective, and what the insurance company will pay,” Tanner said. “Disposing of tidying up opens up a conversation that goes beyond the cost of looking at all of these factors.”
The Guidelines team conducted a systematic review of the literature regarding clinical questions about non-pharmacological and non-pharmacological treatment addressed in the 2017 guide, and for questions about new drug therapies, drug discontinuation, and sequential and combination therapy. The voting committee consisted of two patient representatives and 13 experts representing rheumatology, endocrinology, nephrology, and gastroenterology for adults and children.
A complete manuscript has been submitted for publication in Treatment and research of arthritis, rheumatism and arthritis For peer review, it is expected to be published in early 2023.
Humphrey Worsell, co-principal investigators on the how-to guide, and Robin did not disclose any relevant financial relationships. Tanner reports on a current AMGEN-funded research grant through the University of Alabama at Birmingham and being a paid instructor for the International Society for Clinical Bone Density course, Essentials of Osteoporosis.
Keri Rushton is a writer living in Maryland.