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Corticosteroid-induced osteoporosis

What's new

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

Background

Overview

Definition
Corticosteroids-induced osteoporosis is a form of secondary osteoporosis that is associated with the use of corticosteroids.
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Pathophysiology
Corticosteroids-induced osteoporosis is characterized by increased bone loss secondary to direct and indirect effects of corticosteroids on bone remodeling.
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Epidemiology
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%.
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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.
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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.
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Guidelines

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.
C

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.
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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