Triamcinolone, methylprednisolone avoid prednisone’s fracture risk ‘trap’ in lupus
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WASHINGTON — Although even low-dose prednisone significantly increases the risk for fracture in systemic lupus erythematosus, there is no increased risk from intramuscular triamcinolone or intravenous methylprednisolone, said a speaker.
“Fractures are one of the most common types of organ damage in SLE,” Michelle Petri, MD, MPH, professor of medicine and director of the Lupus Center at the Johns Hopkins University School of Medicine, told Healio. “Corticosteroids greatly increase the risks, but it has been hard to pin down a threshold dose that might be acceptable if really needed to control disease activity.”
To assess the impact of corticosteroid use on fracture risk in SLE, Petri, who presented the findings at ACR Convergence 2024, and colleagues analyzed data on 2,806 patients (92% women; median follow-up: 1.4 years) from a large center from 1988 to 2023.
The researchers calculated the rates of fracture per person-year among subgroups based on exposure to prednisone, intramuscular triamcinolone and intravenous methylprednisolone. Fractures were defined as osteoporosis with fracture or vertebral collapse.
Overall, there were 293 fractures at a rate of 0.13 per person-year. According to the researchers, low doses of prednisone — between 5 mg/day and 9.9 mg/day — significantly increased the risk for fractures. However, this risk also increased with doses even below 5 mg.
The researchers wrote that, “surprisingly,” low levels of 25(OH) vitamin D were not associated with increased fracture risk. Meanwhile, risk factors for fracture included being white, female sex and having low bone mineral density. After adjusting for age and race, fracture risk continued to be associated with female sex, having low bone mineral density and stroke history.
The results indicate that the EULAR 2023 guideline for maintenance doses of prednisone at or below 5 mg/day is “reasonable” for reducing fracture risk, but fracture is still possible, the researchers wrote.
“When patients with SLE flare, they want something that will work quickly,” Petri said. “This has always been the reason that oral prednisone is such a trap — it does work, it works fast, and it is cheap. We found that intramuscular triamcinolone and/or intravenous methylprednisolone did not increase fracture risk. They both work for flares and can be more widely adopted in the clinic.”
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Chao K. Abstract #2679. Presented at: ACR Convergence 2024; Nov. 14-19, 2024; Washington, D.C.
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