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Management of Glucocorticoid-Induced Osteoporosis

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Abstract

This review summarizes the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis (GIOP) management, regulatory requirements, and risk-assessment options. Glucocorticoids are known to cause bone loss and fractures, yet many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated. An European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis workshop was convened to discuss GIOP management and to provide a report by a panel of experts. An expert panel reviewed the available studies that discussed approved therapeutic agents, focusing on randomized and controlled clinical trials reporting on bone mineral density and/or fracture risk of at least 48 weeks’ duration. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. The FRAX algorithm can be adjusted according to glucocorticoid dose. Available antiosteoporotic therapies such as bisphosphonates and teriparatide are efficacious in GIOP management. Several other agents approved for the treatment of postmenopausal osteoporosis may become available for GIOP. It is advised to stop antiosteoporotic treatment after glucocorticoid cessation, unless the patient remains at increased risk of fracture. Calcium and vitamin D supplementation as an osteoporosis-prevention measure is less effective than specific antiosteoporotic treatment. Fracture end-point studies and additional studies investigating specific subpopulations (pediatric, premenopausal, or elderly patients) would strengthen the evidence base and facilitate the development of intervention thresholds and treatment guidelines.

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Acknowledgements

The Alliance for Better Bone Health (Sanofi and Warner Chilcott) provided an unrestricted educational grant to support this publication. The Alliance has had no editorial control over this publication.

Author information

Authors and Affiliations

  1. Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, 1211, Geneva 14, Switzerland

    R. Rizzoli

  2. Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada

    J. D. Adachi

  3. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK

    C. Cooper

  4. NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

    C. Cooper

  5. Amgen, Uxbridge, UK

    W. Dere

  6. Arthritis Unit UCL5390, Université Catholique de Louvain, 1200, Brussels, Belgium

    J. P. Devogelaer

  7. Department of Internal Medicine, Hospital del Mar-IMIM, Universitat Autònoma de Barcelona, Barcelona, Spain

    A. Diez-Perez

  8. RETICEF, Instituto Carlos III, Barcelona, Spain

    A. Diez-Perez

  9. Centre for Metabolic Bone Diseases (WHO Collaborating Centre), University of Sheffield Medical School, Sheffield, UK

    J. A. Kanis

  10. AGES PharmMed, Vienna, Austria

    A. Laslop

  11. Lilly Research Labs, Eli Lilly and Company, Indianapolis, IN, USA

    B. Mitlak

  12. Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands

    S. Papapoulos

  13. School of Molecular and Clinical Medicine and Arthritis Research, Molecular Medicine Centre, Western General Hospital, University of Edinburgh, Edinburgh, UK

    S. Ralston

  14. Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany

    S. Reiter

  15. Department of Endocrinology, CHU Nancy, Vandoeuvre, France

    G. Werhya

  16. Head Bone and Cartilage Metabolism Unit, CHU Centre-Ville, Liège, Belgium

    J. Y. Reginster

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  1. R. Rizzoli
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  2. J. D. Adachi
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  3. C. Cooper
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  5. J. P. Devogelaer
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  7. J. A. Kanis
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  12. S. Reiter
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  14. J. Y. Reginster
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Correspondence to R. Rizzoli.

Additional information

J. A. has received consultant/speaker fees from Amgen, Eli Lilly, GlaxoSmithKline, Merck, Novartis, Pfizer, Procter & Gamble, Roche, Sanofi Aventis, and Warner Chilcott. B. M. is an employee and owns stock in Eli Lilly. S. P. has received consultant/speaker fees from Amgen, Merck, Novartis, GlaxoSmithKline, Eli Lilly, and Roche. J.-Y. R. has received consulting and lecture fees, has been on paid advisory boards, and/or has received grant support from Servier, Novartis, Negma, Lilly, Wyeth, Amgen, GlaxoSmithKline, Roche, Merckle, Nycomed, NPS, Theramex, UCB, Merck Sharp and Dohme, Rottapharm, IBSA, Genevrier, Teijin, Teva, Ebewee Pharma, Zodiac, Analis, Novo-Nordisk, and Bristol Myers Squibb. R. R. has received lecture fees and/or has been on advisory boards for Amgen, Novartis, Servier, Roche, Nycomed, and Danone. S. R. has received consultant/speaker fees from Novartis, Merck, and Eli Lilly. W. D. owns stock in Amgen and Eli Lilly. All other authors have stated that they have no conflict of interest.

Appendix: General Measures and Recommendations in GIOP Management

Appendix: General Measures and Recommendations in GIOP Management

 

General measures

Glucocorticoid-sparing therapy: reduce glucocorticoid dose whenever possible

Consider alternative route of glucocorticoid administration

Advise good nutrition, especially with calcium and vitamin D

Recommend regular weight-bearing exercise

Avoid tobacco use and alcohol abuse

Assess falls risk and advise accordingly

Monitoring recommendations during glucocorticoid therapy

Assess adherence to therapy, including calcium and vitamin D

If suspect vertebral fracture, assess by X-ray or DXA-based vertebral fracture assessment

Measure height annually and BMD at appropriate intervals (especially in patients on high glucocorticoid dose)

Measure serum P1NP after 3 months of teriparatide therapy

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Rizzoli, R., Adachi, J.D., Cooper, C. et al. Management of Glucocorticoid-Induced Osteoporosis. Calcif Tissue Int 91, 225–243 (2012). https://doi.org/10.1007/s00223-012-9630-5

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