2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis

Abstract

This guideline provides direction for clinicians and patients making treatment decisions. Clinicians and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Management of glucocorticoid‐induced osteoporosis: What is new?

“…[15][16][17] Use of the Fracture Risk Assessment Tool (FRAX) algorithm is recommended in a number of guidelines, adjusted for the dose of glucocorticoids. [18][19][20][21][22] However, FRAX has some limitations in this context; in particular, undiagnosed prevalent vertebral fractures, which are associated with increased risk of subsequent fracture and are a strong indication for intervention, lead to underestimation of fracture probability. Vertebral fracture assessment should therefore be performed using lateral DXA images or conventional X-rays if risk factors are present, for example height loss >4 cm, kyphosis, low spine BMD or age ≥70 years.…”

“…In the recent update of the American College of Rheumatology (ACR) guidelines for the management of GIOP, treatment indications for adults aged ≥40 years were partially revised to include 1 or more of the following: a history of fragility fracture, a BMD T-score ≤ −2.5, a FRAX-derived 10-year probability of 10% for major osteoporotic fracture or 1% for hip fracture, and treatment with very high doses of glucocorticoids (not defined). 21 On the one hand, the BMD threshold appears to be unduly high given the higher BMD at which fractures associated with glucocorticoid use occur, while the fracture probability thresholds, particularly that for the hip, appear inappropriately low.…”

Health maintenance for adults with neuromuscular diseases on immunosuppression

“…Bone density monitoring and treatment are important to reduce the risk of fracture. 24 The American College of Rheumatology guidelines recommend that all patients taking ≥2.5 mg of prednisone or equivalent per day for ≥3 months should consume 1,000-1,200 mg of calcium and 600-800 units of vitamin D per day. This can come from diet and/or supplements.…”

“…Patients should also be counseled to make lifestyle modifications to reduce the risk of osteoporosis (smoking cessation, limiting alcohol to 1-2 drinks/day, weight-bearing exercise, and maintaining their body weight in a normal range). 24 Bone mineral density should be measured during the first 6 months of treatment for all patients ≥40 years of age and for younger patients with other osteoporosis risk factors. The Fracture Risk Assessment Tool (FRAX tool) can be used to estimate fracture risk for patients age ≥40 years.…”

“…Repeat bone density monitoring should occur every 1-3 years during treatment. 24 CANCER SCREENING Skin cancer. Chronic immunosuppression increases the incidence and severity of malignant melanoma and nonmelanoma skin cancers ( Table 3).…”