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ACR releases its 2017 guidelines for treating patients with glucocorticoid-induced osteoporosis
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In determining treatment for patients with glucocorticoid-induced osteoporosis, clinicians and patients should collaborate on decision-making based on patient values, preferences and comorbidities, according to recent guidelines published by the American College of Rheumatology.
In the systematic review, researchers queried English-language literature databases, including OVID Medline, PubMed, Embase and the Cochrane Library for published literature about the benefits and harms of glucocorticoid-induced osteoporosis prevention and treatment. Data were collected from the inception of the databases until Oct. 6, 2015. The researchers used the grading of recommendations assessment, development and evaluation methodology to rate the quality of evidence. They developed and applied clinical questions (population/intervention/comparator/outcomes [PICO]). These PICO questions pertained to assessment and reassessment of fracture risks, treatment comparisons, and treatment duration and reassessment. The direction and strength of each recommendation in relation to each PICO question was determined by a voting panel that consisted of adult and pediatric rheumatologists, internists, a nephrologist, a pulmonologist, a gastroenterologist, experts in treating glucocorticoid-induced osteoporosis and a patient.
The following recommendations were determined:
- An initial clinical fracture risk assessment should be performed in all adults and children as soon as possible, but a minimum of 6 months after starting long-term glucocorticoid (GC) treatment;
- In adults aged 40 years or older, it was recommended that this initial evaluation should include use of the FRAX tool with adjustment of GC dose, as well as bone mineral density (BMD) testing if available;
- Patients younger than 40 years should undergo BMD testing if the patient is at high fracture risk due to history of previous osteoporosis (OP) fractures or other significant OP risk factors;
- An annual clinical risk reassessment was recommended for all adult and pediatric patients who continue GC treatment;
- Adults aged 40 years or older who remain on GC treatment and are not treated with an OP medication (beyond calcium and vitamin D), should undergo FRAX with BMD every 1 year to 3 years;
- For adults aged 40 years or older who continue GC treatment and currently take an OP medication, BMD is recommended every 2 years to 3 years in high-risk patients;
- Adults aged 40 years or older who previously received an OP treatment but are no longer on an OP regimen, should undergo BMD testing every 2 years to 3 years;
- All adults younger than 40 years who remain on GC treatment and are at moderate-to-high fracture risk should undergo BMD testing every 2 years to 3 years.
- In patients at low fracture risk, treat with calcium and vitamin D only;
- In patients with moderate-to-high fracture risk, treat with calcium/vitamin D plus another OP medication, ideally oral bisphosphonate;
- In patients for whom oral bisphosphonate is not suitable, continue to treat with calcium/vitamin D, but switch from an oral bisphosphonate to another anti-fracture medication; and
- In adult patients who complete a regimen of oral bisphosphonates but continue to take GCs, continue oral bisphosphonate or switch to another medication as appropriate.
The researchers also discussed recommendations for special populations and outlined recommendations for follow-up treatment in various hypothetical scenarios. According to the researchers, most of the recommendations are conditional or good clinical practice recommendations.
“GIOP is not a problem that is unique to rheumatology; GCs are widely prescribed by primary care providers and subspecialists,” the researchers wrote. “The panel’s judgments regarding patients’ values and preferences were informed by the primary care physicians, non-rheumatology specialists and the patient who served on the panel.” – by Jennifer Byrne
Disclosure: Please see the full study for a list of relevant disclosures.
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