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Corticosteroid-induced osteoporosis

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Updated 2023 ACR and 2019 BSH guidelines for the prevention and management of corticosteroid-induced osteoporosis.



Corticosteroids-induced osteoporosis is a form of secondary osteoporosis that is associated with the use of corticosteroids.
Corticosteroids-induced osteoporosis is characterized by increased bone loss secondary to direct and indirect effects of corticosteroids on bone remodeling.
The annual incidence of vertebral and non-vertebral fractures in patients who initiated corticosteroids within the last 6 months is 5.1% and 2.5%, respectively. For patients on long-term corticosteroid therapy (≥ 6 months), the corresponding figures are 3.2% and 3.0%.
Disease course
Bone loss results from corticosteroid-mediated increases in expression of RANK ligand, which leads to increases in the number of bone-resorbing osteoclasts. Indirect effects of corticosteroids also include decreased renal calcium reabsorption, lower sex steroid hormone levels, in addition to increased PTH activity, which predispose patients to osteonecrosis and fractures.
Prognosis and risk of recurrence
The risk of fracture decreases by 29% after 2-6 months of corticosteroid discontinuation, and becomes similar to non-corticosteroid users by 12 months.


Key sources

The following summarized guidelines for the evaluation and management of corticosteroid-induced osteoporosis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023) and the British Society for Haematology (BSH 2019). ...
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Classification and risk stratification

Fracture risk assessment: as per ACR 2023 guidelines, obtain initial clinical fracture risk assessment including symptomatic and asymptomatic fracture history, FRAX score (age ≥ 40 only), and bone mineral density with vertebral fracture assessment or spine X-rays in all adult patients (≥ 18 years old) initiating or continuing corticosteroid therapy ≥ 2.5 mg/day for > 3 months.
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Medical management

Antiresorptive therapy, low fracture risk: as per ACR 2023 guidelines, do not initiate osteoporosis pharmacotherapy in ≥ 40 years old patients with low fracture risk because of the known risk of harm and no evidence of benefit.

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  • Antiresorptive therapy (moderate fracture risk)

  • Antiresorptive therapy (high or very high fracture risk)

  • Antiresorptive therapy (maintenance)

  • Management of treatment failure

Nonpharmacologic interventions

Calcium and vitamin D supplementation: as per ACR 2023 guidelines, consider optimizing dietary and supplemental calcium and vitamin D in addition to lifestyle modifications in adult and pediatric patients initiating or continuing chronic corticosteroid treatment at low, moderate, high, or very high fracture risk.

Specific circumstances

Pediatric patients
As per ACR 2023 guidelines:
Consider optimizing age-appropriate dietary and supplemental calcium and vitamin D in 4-17 years old pediatric patients with corticosteroids for > 3 months (low or moderate risk). Avoid initiating PO or IV bisphosphonates due to the low risk of osteoporotic fractures in this age group.
Consider initiating PO or IV bisphosphonates in 4-17 years old pediatric patients with an osteoporotic fracture continuing corticosteroid treatment at a dose of ≥ 0.1 mg/kg/day for > 3 months (high risk).

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  • Pregnant patients

  • Patients receiving high-dose corticosteroids

  • Patients with immune thrombocytopenia (fracture risk assessment)

  • Patients with immune thrombocytopenia (osteoporosis management)

  • Patients with immune thrombocytopenia (disease relapse)

  • Solid organ transplant recipients