SANTA BARBARA, CALIF. — About half of patients using glucocorticoids for long periods will suffer compression fractures of the vertebrae if nothing is done to intervene, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.
Bisphosphonate therapy is clearly effective in reducing fractures, whether started when initiating glucocorticoids or after a patient has been on them for a while.
But bisphosphonates aren't enough, and other steps should be taken to manage these patients, said Dr. Lukert of the University of Kansas Medical Center in Kansas City.
Other opportunities to intervene are listed below:
▸ Diet is critical. Since glucocorticoids are catabolic, patients need adequate protein intake, not just calcium and phosphorus.
▸ Heavily encourage patients to exercise, not only because of its benefits on bone. Glucocorticoids often cause myopathy, ranging from mild to severe, and exercise can help to offset this. Strengthening the quadriceps and related muscle groups also has been shown to help prevent falls.
▸ Control urinary calcium. A very large percentage of patients who use glucocorticoids will develop hypercalciuria, and restricting sodium in the diet will go a long way toward resolving this.
▸ Replace hormones as appropriate. Women taking steroids often have low estrogen levels. If premenopausal women become amenorrheic on glucocorticoids, consider prescribing estrogen or progesterone. Dr. Lukert noted that estrogen replacement in postmenopausal women remains controversial.
Patients who have a bone mineral density (BMD) T score of less than -1.5 or are taking more than 10 mg/day of prednisone or the equivalent should receive bisphosphonates as soon as corticosteroids are started.
Patients with a higher BMD taking lower doses of prednisone may hold off on starting bisphosphonates at first and retest BMD after 6 months.
Another reasonable strategy is simply to give a bisphosphonate to all patients who anticipate taking steroids for several weeks or longer.
This strategy is certain to prevent fractures, but at the cost of treating 40%–50% of patients who probably would not have suffered a fracture, even without the bisphosphonate prescription.