Bone-safe glucocorticoid dose ‘hard to find’ in rheumatic, musculoskeletal diseases
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PHILADELPHIA — A daily glucocorticoid dose higher than 2.5 mg may lead to irreversible bone mineral density loss regardless of intervention with osteoporosis medications, according to data presented at ACR Convergence 2022.
“If you give 5 mg of prednisolone in rheumatoid arthritis, you will benefit disease activity,” Giovanni Adami, MD, of the rheumatology unit at the University of Verona, in Italy, said in his presentation. “But what is the tradeoff?”
Adami and colleagues aimed to assess patients with RA, systemic lupus erythematosus, psoriatic arthritis, systemic sclerosis, vasculitides, polymyalgia rheumatica or spondylarthritis for bone mineral density (BMD) and fractures associated with glucocorticoids.
The longitudinal cohort study included 884 women with the aforementioned rheumatic and musculoskeletal diseases and 1,766 controls.
Steroid doses were stratified by mean dosing levels of 0 mg to 2.5 mg per day, 2.5 mg to 5 mg per day and 5 mg or more per day.
According to the researchers, all glucocorticoid users who were not being treated with anti-osteoporotic drugs demonstrated decreases in BMD. Decreases were –2.66% (P = .0006) for the lowest dose, –4.23% (P = .0422) for the middle dose and –4.26% (P = .0011) for the highest dose.
“What is more interesting is that even patients with 2.5 to 5 mg daily, slightly lower doses of glucocorticoids, lost their bone over time,” Adami said.
However, the researchers also explored what happens when patients who have experienced bone loss associated with glucocorticoids are treated with bisphosphonates.
Adami reported that patients being treated with 2.5 mg of glucocorticoids without bisphosphonate therapy lost 4% of bone mineral density. However, those being treated with the same glucocorticoid dose plus bisphosphonates gained 3% in bone mineral density.
Conversely, patients treated with 5 mg of glucocorticoids daily and no bisphosphonates experienced a BMD loss of 4%. With the addition of bisphosphonates in these patients, they still lost 3% of BMD.
“You can reverse the loss and actually increase bone mineral density in patients receiving very low doses of glucocorticoids but not in patients receiving higher doses of glucocorticoids,” Adami said.
Turning to fracture risk, the researchers observed 29 fractures among patients being treated with the lowest dose of steroids, 12 fractures in the middle group and 21 in the highest steroid dose group. These numbers corresponded to a crude fracture rate of 2.5 fractures per 100 person-years, 2.8 fractures per 100 person-year and 4.8 fractures per 100 person-years, respectively.
Adami noted that a 4% bone mineral density loss was associated with a 30% to 40% increase in fracture risk.
“The bone-safe dose of glucocorticoids is hard to find in rheumatic and autoimmune diseases,” Adami said. “It might be lower than 5 mg per day.”
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Adami G. Abstract L01. Presented at: ACR Convergence 2022; Nov. 11-14, 2022; Philadelphia (hybrid meeting).
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