What are the guideline sources, guidelines and references for Corticosteroid-induced osteoporosis ?
Guideline 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 2017). 1 2 3 3 4 4 5 Definition Glucocorticoid-induced osteoporosis is a form of secondary osteoporosis that is associated with the use of glucocorticoids. 2 Epidemiology Glucocorticoid-induced osteoporosis is characterized by increased bone loss secondary to direct and indirect effects of glucocorticoids on bone remodeling. 4 Pathophysiology The annual incidence of vertebral and non-vertebral fractures in patients who initiated glucocorticoids within the last 6 months is 5.1% and 2.5%, respectively. For patients on long-term glucocorticoid therapy ( 6 months), the corresponding figures are 3.2% and 3.0%. 3 Disease course Bone loss results from glucocorticoid-mediated increases in expression of RANK ligand, which leads to increases in the number of bone-resorbing osteoclasts. Indirect effects of glucocorticoids https://web.pathway.md/diseases/recJBdZGDWWvSKjMS 1/4 6/23/23, 3:36 AM Corticosteroid-induced osteoporosis Pathway also include decreased renal calcium reabsorption, lower sex steroid hormone levels, in addition to increased PTH activity, which predispose patients to osteonecrosis and fractures. 4 5 Prognosis and risk of recurrence The risk of fracture decreases by 29% after 2-6 months of glucocorticoid discontinuation, and becomes similar to non-glucocorticoid users by 12 months. 3 Guidelines 1. Classification and risk stratification Fracture risk assessment (adults >= 40 years of age): Classify patients meeting any of the following criteria as being at high risk of fracture: prior osteoporotic fracture(s) hip or spine bone mineral density T score -2.5 in men 50 years of age and postmenopausal women FRAX (corticosteroid-adjusted) 10-year risk of major osteoporotic fracture 20% FRAX (corticosteroid-adjusted) 10-year risk of hip fracture 3%. Classify patients meeting any of the following criteria as being at moderate risk of fracture: FRAX (corticosteroid-adjusted) 10-year risk of major osteoporotic fracture 10-19% FRAX (corticosteroid-adjusted) 10-year risk of hip fracture > 1% and < 3%. Fracture risk assessment (adults < 40 years of age): classify patients with prior osteoporotic fractures as being at high risk of fracture. Show 2 more 2. Medical management General principles: optimize calcium and vitamin D intake, and counsel patients on lifestyle modifications such as maintaining a balanced diet, weight in the recommended range, performing regular weight-bearing or resistance training exercise, limiting alcohol intake to 1-2 alcoholic beverages/day, and discontinuing tobacco use. B Adults >= 40 years, low risk of fracture: optimize calcium and vitamin D intake and lifestyle modifications alone rather than initiating oral antiresorptive agents in patients 40 years of age who are at low risk of fracture. B Adults >= 40 years, moderate risk of major fracture: initiate an oral bisphosphonate (rather than calcium and vitamin D alone) in patients 40 years of age who are at moderate risk of fracture. B Adults >= 40 years, high risk of fracture: initiate an oral bisphosphonate over calcium and vitamin D alone in patients 40 years of age who are at high risk of fracture. B https://web.pathway.md/diseases/recJBdZGDWWvSKjMS 2/4 6/23/23, 3:36 AM Corticosteroid-induced osteoporosis Pathway Adults < 40 years, low risk of fracture: optimize calcium and vitamin D intake and lifestyle modifications alone rather than initiating antiresorptive treatment in adults < 40 years of age who are at low risk of fracture. B Adults < 40 years, moderate risk of fracture: Initiate an oral bisphosphonate over calcium and vitamin D alone in adults < 40 years of age who are at moderate risk of fracture. B Use an oral bisphosphonate rather than intravenous bisphosphonates, teriparatide, or denosumab. B Adults < 40 years, high risk of fracture: Initiate an oral bisphosphonate over calcium and vitamin D alone in adults < 40 years of age who are at moderate risk of fracture. B Use an oral bisphosphonate rather than IV bisphosphonates, teriparatide, or denosumab. B 3. Specific circumstances Pediatric patients: Optimize calcium intake to 1,000 mg/day and vitamin D intake to 600 IU/day, and advise lifestyle modifications in pediatric patients 4-17 years of age treated with corticosteroids for 3 months. E Administer an oral bisphosphonate (or an intravenous bisphosphonate if oral treatment is contraindicated) plus calcium and vitamin D in pediatric patients 4-17 years of age with an osteoporotic fracture who are continuing treatment with corticosteroids at a dose of 0.1 mg/kg/day for 3 months. B Patients of childbearing potential: initiate an oral bisphosphonate in women of childbearing potential who are at moderate or high risk of fracture, do not plan to become pregnant within the period of osteoporosis treatment, and are using effective birth control or are not sexually active. B Patients receiving very high-dose corticosteroids: administer an oral bisphosphonate (rather than calcium and vitamin D alone) for adults 30 years of age receiving very high-dose corticosteroids. B Patients with organ transplants: refer all patients with a renal transplant for evaluation by an expert in metabolic bone disease. B 4. Follow-up and surveillance Long-term maintenance therapy: continue active treatment with an oral bisphosphonate beyond 5 years in patients 40 years of age who have completed 5 years of oral bisphosphonate treatment, who continue corticosteroid treatment, and are assessed to be at moderate-to-high risk of fracture. B https://web.pathway.md/diseases/recJBdZGDWWvSKjMS 3/4 6/23/23, 3:36 AM Corticosteroid-induced osteoporosis Pathway Management of treatment failure: switch to another class of antiresorptive agents in adults 40 years of age who are continuing corticosteroid treatment and have had a fracture that occurred after 18 months of treatment with an oral bisphosphonate, or who have had a significant loss of bone mineral density. Options include denosumab, teriparatide, or intravenous bisphosphonates if treatment failure is judged to be due to poor absorption or poor adherence to oral bisphosphonates. B References 1. Buckley L, Guyatt G, Fink HA et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol. 2017 Aug;69 8 1521 1537. Open 2. Whittier X, Saag KG. Glucocorticoid-induced Osteoporosis. Rheum Dis Clin North Am. 2016 Feb;42 1 177 89, x. Open 3. Compston J. Glucocorticoid-induced osteoporosis: an update. Endocrine. 2018 Jul;61 1 7 16. Open 4. Adami G, Saag KG. Glucocorticoid-induced osteoporosis: 2019 concise clinical review. Osteoporos Int. 2019 Jun;30 6 1145 1156. Open 5. Buckley L, Humphrey MB. Glucocorticoid-Induced Osteoporosis. N Engl J Med. 2018 Dec 27;379 26 2547 2556. Open https://web.pathway.md/diseases/recJBdZGDWWvSKjMS 4/4