Long-Term Glucocorticoid Therapy: Strategies to Reduce the Risk of Osteoporosis

What strategies can reduce the risk of osteoporosis in patients receiving long-term glucocorticoid therapy?

Many patients benefit from early, aggressive therapies that can significantly ameliorate underlying inflammatory pathology. Unfortunately, these agents can adversely affect other organ systems. For example, the treatment of rheumatoid arthritis has been revolutionized by the so-called disease-modifying agents (such as methotrexate and tumor necrosis factor inhibitors), but these drugs also can impair immunity and damage the liver and lungs.

Corticosteroids help control a variety of inflammatory conditions--including dermatologic, rheumatologic, renal, GI, and pulmonary disorders--but they are associated with bone loss (osteopenia or osteoporosis) and immunologic compromise. What can primary care providers do to limit the "collateral damage" of essential but potentially injurious pharmaceuticals?

INSIGHTS FROM A RECENT STUDY

The American College of Rheumatology recommends a baseline bone mineral density measurement, bisphosphonate therapy (alendronate and risedronate are FDA-approved for this indication), and calcium and vitamin D supplementation for patients who are receiving long-term oral corticosteroid therapy at dosages of 5 mg or more per day.¹ Liu and colleagues found that 80% of patients who were receiving long-term corticosteroid therapy for skin disorders were not given concurrent bisphosphonate therapy.^2,3 In addition, only 18 of 35 patients in this cohort underwent initial bone mineral density scans. At a later date, although 7 had normal bone density, 8 had osteopenia and 3 had osteoporosis.

The patients in this study had been taking prednisone for an average of 17 months. This duration of therapy is typical of that used for other indications that require corticosteroids, such as asthma, systemic lupus erythematosus, solid organ transplantation, and ulcerative colitis.

Another take-home message from this study is that the greatest loss of bone occurs during the first 6 months of therapy.³ Even though the adage "Better late than never" still applies, earlier intervention is much more protective of patients' bone integrity.

Subspecialty care is now replete with an armamentarium that can change the course of certain diseases in ways we could not have imagined 10 years ago. But there is still a critical role for primary care in mitigating the untoward effects of "wonder drugs."

References:

REFERENCES:

1.

American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update.

Arthritis Rheumatism

. 2001;44:1496-1503.

2.

Liu RH, Albrecht J, Werth VP. Cross-sectional study of bisphosphonate use in dermatology patients receiving long-term oral corticosteroid therapy.

Arch Dermatol

. 2006;142:37-41.

3.

Minerd J, Agus Z. Doctors may neglect bone loss when prescribing steroids. Available at: http:// www.medpagetoday.com/rheumatology/general rheumatology/tb/2495. Accessed May 19, 2006.