Updated Guidelines and New Therapies for Osteoporosis Coming this Year

PHILADELPHIA—Updated recommendations for treatment of glucocorticoid-induced osteoporosis are expected to be released in 2010. In a presentation about the updated guidelines at the ACR Annual Scientific Meeting in October 2009, Jennifer M. Grossman, MD, principal investigator on the guideline development project, said that many patients on long-term glucocorticoid therapy do not get the interventions they need, despite the availability of therapies that would reduce their fracture risk.

The guidelines, updated from the 2001 recommendations, were submitted to the ACR in December, with the board of directors expected to review them this month. Pending peer review and acceptance, the final guidelines will be published in Arthritis Care & Research.

In addition to an overview of the preliminary recommendations, speakers at the session on osteoporosis care presented information about the online fracture risk assessment tool, known as FRAX, and provided an update on treatment options, including those in the pipeline.

Decreased Bone Mass

Dr. Grossman, associate clinical professor of medicine in the department of rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles, said there “may be no safe dose” of daily steroids, a class of medications that is “not without complications.”

The effects of glucocorticoids on osteocytes, osteoclasts, the neuroendocrine system, and calcium metabolism lead to decreased bone mass; their effect on muscle heightens the risk of falls and subsequent fractures, she said. Risk of nonvertebral fracture increases with daily doses as low as 2.5 mg to 5 mg.

Even though these risks are known, only about 50% of women and 20% of men on glucocorticoids are given bone density studies; 10% to 50% of women and 10% to 20% of men receive prescription therapy for prevention or treatment of glucocorticoid-induced osteoporosis, Dr. Grossman said.

In her overview of the preliminary guidelines, Dr. Grossman said that any patient expected to use a glucocorticoid for three months or longer should be counseled about the need for adequate calcium and vitamin D intake and should be asked about any history of minimal trauma fractures. Physicians should observe their patient’s gait, take an annual height measurement, encourage smoking cessation, and urge limitation of alcohol intake to no more than two drinks daily. A bone density scan should be ordered if the patient has an established history of glucocorticoid use.

Recommendations for therapy in the updated guidelines will be based on an individual patient’s 10-year fracture risk as determined by FRAX. However, according to Dr. Grossman, the guidelines panel concluded that data are limited to guide treatment decisions for premenopausal women and men younger than 50 years.

Using FRAX

Michael McClung, MD, founding director of the Oregon Osteoporosis Center in Portland and an advisor to the World Health Organization’s fracture risk task force, said that the strength of FRAX is that the “interrelationships among the independent fracture risks are incorporated into the computer model,” rather than simply basing fracture risk on bone mineral density (BMD).

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