PREVENTING AND TREATING BONE LOSS DUE TO GLUCOCORTICOIDS
Effective options are available to prevent the deleterious effects of glucocorticoids on bone.
A plethora of guidelines offer direction on how to reduce fracture risk—ie, how to maintain bone mineral density while preventing additional bone loss, alleviating pain associated with existing fractures, maintaining and increasing muscle strength, and initiating lifestyle changes as needed. 17,18 Guidelines from the American College of Rheumatology (ACR), 17 published in 2001, are being updated. United Kingdom (UK) guidelines, 18 published in December 2002, differ slightly from those of the ACR.
Limit exposure to glucocorticoids
Oral glucocorticoids should be given in the lowest effective dose for the shortest possible time. However, there is no safe oral glucocorticoid dose with respect to bone. Alternate-day dosing suppresses the adrenal axis less but has the same effect as daily dosing with regard to bone.
Recommend lifestyle measures from day 1
All guidelines recommend that as soon as a patient is prescribed a glucocorticoid, the clinician should prescribe certain preventive measures, including:
- Smoking cessation
- Weight-bearing and strength-building exercises
- Calcium intake of 1,000 to 1,500 mg per day
- Vitamin D 800 to 1,000 IU per day.
Calcium and vitamin D for all
The Cochrane Database of Systematic Reviews 19 evaluated the data supporting the recommendation to use calcium and vitamin D as preventive therapy in patients receiving glucocorticoids. Five trials with 274 patients were included in the meta-analysis. At 2 years after starting calcium and vitamin D, there was a significant weighted mean difference of 2.6% (95% confidence interval [CI] 0.7–4.5) between the treatment and control groups in lumbar spine bone mineral density.
The authors concluded that because calcium and vitamin D have low toxicity and are inexpensive, all patients starting glucocorticoids should also take a calcium and a vitamin D supplement prophylactically.
Bisphosphonates are effective and recommended
The ACR 17 and UK 18 guidelines said that bisphosphonates are effective for preventing and treating bone loss in patients receiving glucocorticoids.
More recently, Stoch et al 20 evaluated the efficacy and safety of alendronate (Fosamax) 70 mg weekly for preventing and treating bone loss in patients on glucocorticoid therapy. At 12 months, bone mineral density in the lumbar spine, trochanter, and total hip had increased from baseline in the alendronate group and was significantly higher than in the placebo group. At the same time, levels of biochemical markers of bone remodeling were significantly lower than at baseline in the alendronate group.
For premenopausal women, postmenopausal women on estrogen replacement therapy, and men, the ACR 17 recommends risedronate (Actonel) 5 mg per day or alendronate 5 mg per day; for postmenopausal women not on estrogen, risedronate 5 mg per day or alendronate 10 mg per day is recommended.
Who should receive a bisphosphonate?
In men and postmenopausal women, the ACR 17 recommends a bisphosphonate for patients starting long-term glucocorticoid treatment (ie, expected to last 3 months or more) in doses of 5 mg or more per day of prednisone or its equivalent, irrespective of bone mineral density values.