The American College of Rheumatology 2010 recommendations replace the 2001 guidelines, recognizing that “new pharmacologic therapies for the treatment of osteoporosis have been approved and additional information on previously recommended medications has been reported.”
The ACR report, published online July 26 in Arthritis Care & Research, notes that bone mineral density declines rapidly within the first 3 months of glucocorticoid use and peaks at 6 months; with continued used, a slower, steady loss follows.
However, “many patients on long-term glucocorticoids do not receive any interventions to prevent or treat osteoporosis,” lead author Dr. Jennifer M. Grossman of the University of California, Los Angeles, and colleagues point out.
The updated guidelines classify patients into three fracture risk categories — high, medium and low risk — based on gender, age, race/ethnicity, and femoral neck bone-density T scores. Management recommendations take into consideration the dosage and anticipated duration of glucocorticoid therapy.
Based on a systematic review of therapies currently approved for the treatment of postmenopausal osteoporosis or glucocorticoid-induced osteoporosis, the report includes algorithms outlining recommended approaches for postmenopausal women and men over age 50 years and for premenopausal women and men under age 50, who are starting or are on glucocorticoid therapy.
For the older group of patients, stepwise management begins with counseling and risk factor assessment, then determination of the fracture risk category. If the risk is high, for example, and glucocorticoid dosage is less than 5 mg/d and expected to last less than a month, treatment with alendronate, risedronate, zoledronic acid is recommended.
For the younger age group, there is not adequate evidence to make recommendations if there is no prevalent fragility fracture; if there is, then treatment recommendations again depend the duration and dosage of glucocorticoid therapy, as well s the childbearing potential of women in this group.
The authors note that while zoledronic acid and teriparatide are now recommended along with alendronate and risedronate, data were insufficient for the panel to recommend the use of ibandronate, etidronate, calcitonin, estrogen, testosterone and raloxifene. In fact, “the previously included therapies estrogen replacement and testosterone are no longer endorsed.”
The report concludes that the recommendations are likely to undergo future revisions as new evidence becomes available.
American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis
Arthritis Care Res 2010.