ACR Releases Update to Glucocorticoid-Induced Osteoporosis Guideline

However, the guideline now conditionally recommends parathyroid hormone-based agents over both bisphosphonates or denosumab for adults with very high risk of fracture. This is partly based on a head-to-head study of teriparatide and alendronate, which found that teriparatide increased lumbar and hip bone mineral density and decreased vertebral, but not non-vertebral, fractures at 36 months in glucocorticoid-induced osteoporosis.⁶ For adults at high risk of fracture, parathyroid hormone-based treatments or denosumab are conditionally recommended over bisphosphonates.

In contrast, for adults at moderate risk of fracture, the conditional recommendation is for oral or intravenous bisphosphonates, parathyroid hormone-based treatments or denosumab. Pharmacologic treatment is not recommended for low-risk patients taking glucocorticoids.

The guideline also conditionally recommends against both romosozumab and raloxifene, except in high or very high-risk patients who don’t tolerate other anti-osteoporotic agents. This recommendation is rooted in the uncertain safety profiles of these agents with respect to cardiovascular dangers.

Dr. Humphrey points out that because of SERMs’ potential to protect against breast cancer, they can be helpful agents for some women with a high breast cancer risk who also need osteoporotic protection. “But there is also an increased risk of stroke and heart attack from these agents that became more apparent in the last few years,” she adds. “So you really have to do a careful risk assessment.”

Dr. Humphrey

Dr. Russell underscores that when choosing an initial medication for a patient, one should factor in the patient’s comorbidities. For example, an oral bisphosphonate might not be appropriate for a patient with chronic gastroesophageal reflux disease, since acid reflux is one of the most common side effects of these drugs. Other patient preference factors, such as willingness to take a daily injection, e.g., for teriparatide, must also be considered.

However, Dr. Humphrey points out that, on a practical level, many patients may not be able to get coverage for certain osteoporosis medications, at least not initially, due to cost differences. “Many of the insurance companies have been holding back on covering teriparatide, abaloparatide, romosozumab and sometimes even denosumab, except for people with really severe osteoporosis, people who have had a prior fractures or people who have failed these other drugs,” she notes.

To date, neither abaloparatide nor romosozumab have achieved FDA approval for people with glucocorticoid-induced osteoporosis, which may also affect insurance coverage.

Sequential Therapy

When talking with patients about their initial choice for osteoporotic prevention, Dr. Humphrey believes it is also important to talk about the eventual need for sequential therapy, which might influence the treatment preference. New recommendations about sequential therapy were a key addition to the updated glucocorticoidinduced osteoporosis guideline.