ATLANTA—Although glucocorticoids have clinical benefits for lupus and other rheumatic conditions, they can lead to an increased risk for fractures related to glucocorticoid-induced osteoporosis (GIOP). Now, with new agents available and an even more diverse group of patients than ever, clinicians decided to update the recommendations. At the ACR/ARHP 2010 Annual Scientific Meeting, Dr. Grossman, lead author of the new recommendations, discussed how the recommendations were developed and the new developments that were considered in the update.
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The panel that worked on the recommendations included specialists from UCLA, the University of Alabama at Birmingham, and the University of Colorado. To assist with their recommendations, the panel conducted a systematic review of research papers on the topic published between 1966 and 2008.
Glucocorticoids can lead to decreased bone formation, bone quality, and bone mass, all of which increase the risk for fracture, Dr. Grossman said. They also affect the neuroendocrine system and calcium metabolism, both leading to increased bone resorption. “Last but not least are the effects of glucocorticoids on muscle,” Dr. Grossman said. “This leads to myopathy, muscle weakness, and subsequent falls.” Studies show that there is an increased risk for fracture with day-to-day glucocorticoid use and increased daily dosages, Dr. Grossman said.2
Although the risk for osteoporosis associated with glucocorticoids is well known, this does not mean the risk is always addressed, Dr. Grossman said. One study that used data from a U.S. managed care organization during an 18-month period analyzed patients who had been prescribed glucocorticoids and had taken them for at least two months.3 Although 42% of the 6,281 patients analyzed underwent bone mass measurement, the rate was actually lower for men, at only 25%. African American patients were less likely to be screened for bone mineral density than white patients, the study found.
“With all this knowledge, we sought to update the 2001 ACR recommendations. The purpose of such a project is to develop statements to assist practitioner and patient decisions about appropriate health care for specific clinical situations,” Dr. Grossman said.
As a wide range of GIOP patients could be analyzed, the panel decided to limit their recommendations somewhat. They did not include childhood GIOP, transplant GIOP, or patients on inhaled steroids only or IV pulse steroids only. They limited the medications analyzed to those approved by the U.S. Food and Drug Administration or for use in Canada or Europe to treat osteoporosis.
The new recommendations also take into consideration changes made to the Fracture Risk Assessment Tool (FRAX).4 FRAX now has updated evidence-based estimates of absolute fracture risk. Practitioners can use the FRAX calculation tool to find out a patient’s 10-year probability of fracture. FRAX uses clinical risk factors along with bone mineral density at femoral neck to determine a patient’s probability percentage. Consistent with guidelines from the National Osteoporosis Foundation, the new recommendations define patients with a 10% risk or less as low risk, 10–20% as at medium risk, and greater than 20% or a T score of less than or equal to –2.5 as high risk. Someone with a history of fragility fracture is also high risk, according to the new recommendations.
Although FRAX has some limitations—for example, it does not consider dose response effects and is relevant only for untreated patients—Dr. Grossman said the tool remains useful for clinicians.
The 2010 recommendations also added newer agents such as zoledronic acid and teriparatide but removed therapies such as estrogen replacement and testosterone, she said.
The new recommendations from include graphs that make it easy to determine a patient’s risk for fracture based on their FRAX results, race, age, and, for women, whether or not they are premenopausal or postmenopausal (see Figures 1 and 2, p. 44).
Vanessa Caceres is a medical writer in Bradenton, Florida.
- Grossman JM, Gordon R, Ranganath VK, et al. American College of Rheumatology 2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res. 2010;62:1515-1526.
- Van Staa TP, Laan RF, Barton IP, Cohen S, Reid DM, Cooper C. Bone density threshold and other predictors of vertebral fracture in patients receiving oral glucocorticoid therapy. Arthritis Rheum. 2003;48:3224-3229.
- Curtis JR, Westfall AO, Allison JJ, et al. Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients. Arthritis Rheum. 2005;52:2485-2494.
- World Health Organization Collaborating Centre for Metabolic Bone Diseases. WHO Fracture Risk Assessment Tool. www.shef.ac.uk/ FRAX. Accessed January 26, 2011.