2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis

Abstract

ObjectiveThe objective is to update recommendations for prevention and treatment of glucocorticoid‐induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily.MethodsAn updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations.ResultsFor adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x‐ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision‐making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high‐dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included.ConclusionThis guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.

Clinical Pharmacology in Sarcoidosis: How to Use and Monitor Sarcoidosis Medications

“…Treatment recommendations for loss of bone density are based on the FRAX ® score. If available, bone-mineral density (BMD) testing with vertebral-fracture assessment (VFA) or spinal x-ray is recommended as soon as possible after starting glucocorticoid therapy as a baseline measurement, and then every 1–2 years thereafter while continuing a glucocorticoid regimen [ 7 ].…”

“…Osteoporosis : For the prevention and treatment of glucocorticoid-induced osteoporosis, the American College of Rheumatology guidelines suggest specific recommendations for adults who are taking a prednisone equivalent of ≥2.5 mg daily for >3 months, based on the individual patient’s level of risk: low risk, moderate, high, and very high risk, respectively [ 7 ]. These levels of risk are based on the glucocorticoid dose, dual-energy X-ray absorptiometry (DEXA) T score and Z score, FRAX ® score, and a prior history of osteoporosis-related fracture.…”

“…These levels of risk are based on the glucocorticoid dose, dual-energy X-ray absorptiometry (DEXA) T score and Z score, FRAX ® score, and a prior history of osteoporosis-related fracture. Specific details can be found in the 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis [ 7 ].…”

“…The American College of Rheumatology guidelines recommend osteoporosis monitoring for all adults initiating glucocorticoid therapy or continuing glucocorticoid therapy ≥2.5 mg/day for more than three months. [7] An initial fracture-risk assessment using the clinical fracture-risk factor assessment (FRAX ® , https://frax.shef.ac.uk/FRAX/tool.aspx, accessed on 20 November 2023) is strongly recommended for all such patients, including for those who have never had a fracture-risk assessment or have been previously treated for osteoporosis. FRAX ® estimates the fracture risk based on many factors including alcohol use, smoking history, hypogonadism, history of prior fractures, body weight, height, parental history of hip fracture, fall history, rheumatoid arthritis, thyroid disease, hyperparathyroidism, malabsorption, chronic liver disease, inflammatory bowel disease, and height loss.…”

Dermatomyositis: Practical Guidance and Unmet Needs

“… 18 As glucocorticoids are a major contributor to impaired bone health in DM patients, it is paramount for physicians to follow published guidelines to prevent and treat glucocorticoid-induced osteoporosis in DM patients. 19 …”