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.

Development and Comparison of Treatment Decision Tools for Glucocorticoid-Induced Osteoporosis

“…Current treatment recommendations are summarized in Supplementary Table S1. According to ACR recommendations (2017 and 2022 update) [20,27], AOT is recommended for moderate, high, or very high risk patients, who are defined as adults over 40 years of age with prior osteoporotic fractures, a hip or spine BMD T-score below −1, a GC-FRAX score above 10% for major osteoporotic fractures or over 1% for hip fractures, or with very high doses of GCs (≥30 mg/day for >30 days or a cumulative dose of ≥5 g/year) [20]. IOF-ECTS recommended AOT in patients over 70 years old or with a previous fragility fracture, for those under high dosage prednisolone or equivalent doses, or those above country-specific intervention thresholds.…”

“…Although country-specific intervention thresholds assessed by FRAX, presented as a fixed or age-dependent value, are widely used in postmenopausal women [18], GC-FRAX-based intervention thresholds require further validation. Other treatment recommendations are more complicated, incorporating multiple convention risk factors in combination with the GC-FRAX intervention threshold [19], such as ACR [20] and the International Osteoporosis Foundation and European Calcified Tissue Society (IOF-ECTS, Supplementary Table S1) [21]. These suggestions are predominantly decided on by the systemic review of published randomized controlled trials and experts' consensus [19] rather than the clinical database.…”

Review of 2022 American College of Rheumatology (ACR) guideline for the prevention and treatment of glucocorticoid-induced osteoporosis: what’s new?

“…2. Рекомендации по лечению остеопороза при прекращении приема глюкокортикоидов (ГК) (адаптировано из [6]): МПК -минеральная плотность костей; СО -стандартное отклонение; БФ -бисфосфонаты Во-вторых, появились новые лекарственные препараты для лечения ОП. В-третьих, широко обсуждаются вопросы назначения анаболических препаратов как лекарственных средств первого выбора у пациентов с очень высоким риском перелома.…”

“…В августе 2022 г. Американская коллегия ревматологов (ACR, American College of Rheumatology) одобрила новую версию рекомендаций по ГК ОП, однако в последующем она была доработана в ноябре 2022 г. и июле 2023 г.. Это уже пятая редакция данных клинических рекомендаций [6], а первые были опубликованы еще в 1996 г. Затем они дополнялись в 2001, 2010 и 2017 гг., что было связано с появлением новых техник для оценки риска переломов и новых лекарственных препаратов, доказавших свою эффективность при первичном и ГК ОП.…”