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Corticosteroid use leads to higher osteoporotic fracture risk
High-dose steroids led to a fourfold increase in vertebral fracture risk; hip fracture risk doubled.
TORONTO – To avoid corticosteroid-induced osteoporosis and potential fractures, patients should consider taking bisphosphonates, says a rheumatologist here at the International Osteoporosis Foundation World Congress on Osteoporosis.
“When patients are placed on steroids, even at a dosage as low as 2.5 mg per day and irrespective of the duration of therapy, we see an increase in bone loss and in the rate of fracture,” said Jonathan D. Adachi, MD, a rheumatologist and professor in the department of medicine at McMaster University in Hamilton, Canada.
One epidemiologic study conducted in the United Kingdom with about 500,000 patients found high doses of corticosteroids, exceeding 7.5 mg per day, led to a fourfold increased risk of vertebral fracture and doubled the hip fracture risk. Lower doses, ranging from 2.5 mg and 7.5 mg, prompted a two-and-a-half-fold elevated risk of vertebral fractures and raised the hip fracture risk by more than 75%.
Use lowest dose possible
“It’s important to get patients down to as low a dose of steroids as possible,” said Adachi, noting the relationship between dosage and fracture risk. “We would like to get the patients off steroids as quickly as we can. We don’t have all the answers in steroid use and osteoporosis.”
Particular patient groups, such as postmenopausal women, have a greater need for bone protection and should consider therapies like bisphosphonates, calcitonin or hormone replacement therapy.
“In postmenopausal women who are placed on steroids, it is advisable to start them on bisphosphonates,” he said. “When this group of women is placed on steroids, we start to see an increase in vertebral fracture risk in the first few months of therapy on steroids. In women who are premenopausal and on steroids, it is less clear if they should be administered bisphosphonates because estrogen protects their bones. The level of risk of fracture for men over age 50 is not well known; however, the benefit of bisphosphonates has been demonstrated.”
Perimenopausal women should talk to their physicians to decide if they want bisphosphonates to reduce their fracture risk.
Some concerns
There are some concerns about women of childbearing age using bisphosphonates, according to Adachi.
“You don’t want to give someone a drug if you don’t know what the consequences might be,” said Adachi, noting there are scant data on bisphosphonate drugs taken during pregnancy. “There may be no consequences of getting pregnant while on a bisphosphonate, but why take a chance?”
In patients who are taking corticosteroids for the treatment of arthritis, asthma or another condition, it is important that clinicians look at other factors when evaluating a patient’s risk of fracturing or developing osteopenia or osteoporosis, Adachi said.
“Factors such as age, previous fracture, measurement of bone mineral density (T-score), smoking, the presence of chronic obstructive pulmonary disease, and inflammatory bowel disease can all influence the decision for bone therapy for a patient who is taking corticosteroids,” Adachi said. “If a patient has a comorbidity like Crohn’s disease, I would be more inclined to give treatment.”
Because a bone mineral density measurement is not always readily available, Adachi said he would advise clinicians to prescribe protective bone therapy such as bisphosphonates while they wait for the results of the BMD test. He added that complications, such as jaw osteonecrosis, are not a concern when bisphosphonates are used in settings outside of oncology treatment.
For more information:
- Adachi JD. Corticosteroid-induced osteoporosis. Presented at the IOF World Congress on Osteoporosis. June 2-6, 2006. Toronto.