Clinical Pearls & Morning Reports
Numerous randomized trials have shown that bisphosphonates (alendronate, risedronate, zoledronate, and ibandronate) increase bone mineral density in patients who receive glucocorticoids. Given their low cost and good safety profile, oral bisphosphonates are recommended as first-line agents to prevent glucocorticoid-induced fractures unless there are contraindications or unacceptable side effects. Read the latest NEJM Clinical Practice article here.
Q: When should one screen for fracture risk in patients receiving glucocorticoids?
A: Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. Vertebral fractures are the most common fractures associated with glucocorticoids; the risk of vertebral fracture increases within 3 months after initiation of treatment and peaks at 12 months.
Q: What are some of the nonpharmacologic recommendations for patients receiving glucocorticoids?
A: For patients who receive glucocorticoids, routine lifestyle recommendations that are based on observational data largely from patients who have not received glucocorticoids include weight-bearing exercise, maintenance of normal weight, smoking cessation, limitation of alcohol consumption, and the assessment and management of fall risks.
A: Prevention of glucocorticoid-induced fractures requires identification of patients who should receive treatment. The fracture risk assessment tool (FRAX) combines many risk factors for osteoporosis (including glucocorticoid use) with the bone mineral density to provide an estimate of the 10-year risk of major osteoporotic fracture and hip fracture among patients who are at least 40 years of age. Although the risk of fracture can be calculated when the bone mineral density T score is not available, bone mineral density testing is recommended for people who receive glucocorticoids and are at least 40 years of age, since this testing improves the accuracy of FRAX estimates. Currently, tools to estimate the risk of fracture among patients who are younger than 40 years of age are lacking. When glucocorticoid use is added as a risk factor in the FRAX tool, the fracture estimates reflect the risk associated with prednisone at a dose of 2.5 to 7.5 mg per day; however, analysis of data from the U.K. General Practice Database suggests that among patients who receive more than 7.5 mg of prednisone daily, the FRAX-predicted risk of major osteoporotic fracture has to be increased by 15% and the risk of hip fracture has to be increased by 20%. However, among patients who receive very high doses of prednisone (>30 mg per day or cumulative doses to >5 g per year), this adjustment may underestimate the risk of fracture. Another limitation of the FRAX score calculation is the use of bone mineral density at the hip instead of at the lumbar spine, since glucocorticoids have the greatest negative effect on trabecular bone in the spine.
A: The 2017 guidelines of the American College of Rheumatology recommend pharmacologic treatment to prevent additional fractures in any patient with a previous osteoporotic fracture who is receiving glucocorticoids (prednisone dose >2.5 mg per day). Among patients who are receiving glucocorticoids and have a bone mineral density T score of −2.5 or less at either the spine or the femoral neck, pharmacologic treatment is also recommended for men who are 50 years of age or older and for postmenopausal women. Among adults who are 40 years of age or older and who do not meet the above criteria, pharmacologic treatment is recommended if the 10-year risk of major osteoporotic fracture is at least 20% or if the risk of hip fracture is at least 3% according to the FRAX tool (after increasing the risk by 15% and 20%, respectively, for a prednisone dose >7.5 mg daily).