Relationship Between Systemic Corticosteroids and Osteonecrosis

Abstract

Numerous reports describe osteonecrosis after oral corticosteroid therapy. It is still uncertain if corticosteroid treatment alone or in combination with other factors leads to the development of this condition. The literature presents controversial clinical and experimental data. The most affected site for osteonecrosis is the femoral head and therefore our considerations are concentrated at this site. Oral corticosteroids are commonly used in dermatology, especially in the treatment of connective tissue diseases and hypersensitive diseases. This clinical review evaluates the relationship between and the onset of femoral head necrosis. Although osteonecrosis of the femoral head can be caused by various conditions such as trauma, excess alcohol and hemoglobinopathies, studies indicate that treatment with corticosteroids is the most common cause of the condition. There is some controversy on the role of underlying disease and total corticosteroid dose administered, in the development of osteonecrosis of the femoral head. MRI scans are used to establish an early diagnosis. There are several surgical and nonsurgical options for disease management, dependent on the stage of disease, the age of the patient and other risk factors. In general, the risk for osteonecrosis is considered to be low under oral corticosteroid therapy. So far, no data can establish a direct relationship, but data still strongly suggest an existing cause and effect relationship. Further investigations are necessary for example, a large controlled prospective long-term study, to further refine an association between the corticosteroid dose, the duration of treatment and other risk factors. Dermatologists who prescribe oral corticosteroids, should always be aware of the potential risk of avascular femoral head necrosis and the patients should be informed about this severe complication of oral coricosteroid therapy.

Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data

“…This is one of the reasons why some authors question the evidence that GC are actually responsible for osteonecrosis. 28 Although the occurrence of GC related osteonecrosis seems to be dose dependent, this might be confounded by the fact that higher doses are related to more severe underlying disease and increased risk of osteonecrosis. One study reported osteonecrosis in 2.4% of patients receiving GC replacement treatment, 29 but data on low dose GC treatment are scarce and mostly anecdotal.…”

ACTH protects against glucocorticoid-induced osteonecrosis of bone

“…osteoporosis | osteoclast | osteoblast T he use of glucocorticoids for medical conditions as diverse as asthma, ulcerative colitis, kidney diseases, and rheumatologic disorders causes not only a variety of metabolic and medical complications, including diabetes and osteoporosis, but also a painful debilitating condition, osteonecrosis, usually affecting the femoral head (1). Osteonecrosis almost invariably requires surgical debridement of dead bone and contributes to approximately 10% of the more than 500,000 hip replacements annually in the United States (2).…”

Side Effects of Short-Term Oral Corticosteroids

“…3 Long-term CS is known to be associated with the development of avascular necrosis (AVN) (synonyms: osteonecrosis, ischemic necrosis, or aseptic necrosis). [29][30][31][32] A number of authors have also noted the relationship between AVN and short-term CS use, [33][34][35] and McKee and colleagues in 2001 reported 15 cases of AVN following short-term CS therapy, with the lowest cumulative dose being 290 mg. 33 (I spoke with Dr. McKee in December 2006, and they have now seen over 100 cases.) Osteoporosis has not been reported to be a problem with short-term CS, but patients should continue with their normal preventive measures, such as calcium, vitamin D, and bisphosphonates, if relevant.…”