Misplaced Pages

Steroid-induced osteoporosis is osteoporosis arising from the use of glucocorticoids (a class of steroid hormones) analogous to Cushing's syndrome but involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Bisphosphonates are beneficial in reducing the risk of vertebral fractures. Some professional guidelines recommend prophylactic calcium and vitamin D supplementation in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when this is in excess of three months. The use of thiazide diuretics, and gonadal hormone replacement has also been recommended, with the use of calcitonin, bisphosphonates, sodium fluoride or anabolic steroids also suggested in refractory cases. Alternate day use may not prevent this complication.

It is also known as glucocorticoid-induced osteoporosis.

Mechanism

Mechanisms of SIOP include:

• Direct inhibition of osteoblast function
• Direct enhancement of bone resorption
• Inhibition of gastrointestinal calcium absorption
• Increased urine calcium loss
• Inhibition of sex steroids

Diagnosis

The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density (BMD). The most popular method of measuring BMD is Dual-energy X-ray absorptiometry. A clinical diagnosis of SIOP can be made following a fragility fracture in a patient taking steroids.

In addition to the detection of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially modifiable underlying causes; this may be done with blood tests. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone, multiple myeloma, Cushing's disease and other above-mentioned causes may be performed.

Prevention and Treatment

To prevent steroid-induced osteoporosis, the steroid dose and duration should be as low and as short as possible. All patients on long term glucocorticoids (≥3 months) should be encouraged to do weightbearing exercise, avoid smoking and excess alcohol and take fall prevention measures. Daily calcium and vitamin d intake should be sufficient. DXA scans can be used in combination with the FRAX tool to assess the risk of future fractures for decisions on pharmacological treatment. Importantly, FRAX does not take into account the dose and duration of glucocorticoid.

The International Osteoporosis Foundation and the European Calcified Tissue Society recommend pharmacological therapy for osteoporosis in postmenopausal women and men ≥70 years, with a previous fragility fracture, or a dose equivalent of prednisone ≥7.5 mg daily for ≥3 months. For premenopausal women and men <50 years taking steroids for ≥3 months, osteoporosis therapy should be considered for those with a history of a fragility fracture. For all others, treatment decisions are individualized based upon patient characteristics and clinical judgement.

References

1. Allen CS, Yeung JH, Vandermeer B, Homik J (October 2016). "Bisphosphonates for steroid-induced osteoporosis". The Cochrane Database of Systematic Reviews. 2016 (10): CD001347. doi:10.1002/14651858.CD001347.pub2. PMC 6461188. PMID 27706804.
2. Bone and Tooth Society of Great Britain, National Osteoporosis Society, Royal College of Physicians (2003). Glucocorticoid-induced Osteoporosis (PDF). London, UK: Royal College of Physicians of London. ISBN 978-1-86016-173-5.{{cite book}}: CS1 maint: multiple names: authors list (link)
3. Homik J, Suarez-Almazor ME, Shea B, Cranney A, Wells G, Tugwell P (2000). "Calcium and vitamin D for corticosteroid-induced osteoporosis". The Cochrane Database of Systematic Reviews. 1998 (2): CD000952. doi:10.1002/14651858.CD000952. PMC 7046131. PMID 10796394.
4. Buckley, Lenore; Guyatt, Gordon; Fink, Howard A.; Cannon, Michael; Grossman, Jennifer; Hansen, Karen E.; Humphrey, Mary Beth; Lane, Nancy E.; Magrey, Marina; Miller, Marc; Morrison, Lake (August 2017). "2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis". Arthritis Care & Research. 69 (8): 1095–1110. doi:10.1002/acr.23279. ISSN 2151-4658. PMID 28585410.
5. Lukert BP, Raisz LG (March 1990). "Glucocorticoid-induced osteoporosis: pathogenesis and management". Annals of Internal Medicine. 112 (5): 352–64. doi:10.7326/0003-4819-112-5-352. PMID 2407167.
6. Gourlay M, Franceschini N, Sheyn Y (February 2007). "Prevention and treatment strategies for glucocorticoid-induced osteoporotic fractures". Clinical Rheumatology. 26 (2): 144–53. doi:10.1007/s10067-006-0315-1. PMID 16670825. S2CID 26017061.
7. Buckley, Lenore; Guyatt, Gordon; Fink, Howard A.; Cannon, Michael; Grossman, Jennifer; Hansen, Karen E.; Humphrey, Mary Beth; Lane, Nancy E.; Magrey, Marina; Miller, Marc; Morrison, Lake (August 2017). "2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis". Arthritis Care & Research. 69 (8): 1095–1110. doi:10.1002/acr.23279. ISSN 2151-4658. PMID 28585410.
8. Steroid-induced osteoporosis By Susan Ott, MD. Updated January 28, 2009. Retrieved on 26 March 2009
9. Kanis, J. A.; Johansson, H.; Oden, A.; McCloskey, E. V. (2011-03-01). "Guidance for the adjustment of FRAX according to the dose of glucocorticoids". Osteoporosis International. 22 (3): 809–816. doi:10.1007/s00198-010-1524-7. ISSN 1433-2965. PMID 21229233. S2CID 21223590.
10. Lekamwasam, S.; Adachi, J. D.; Agnusdei, D.; Bilezikian, J.; Boonen, S.; Borgström, F.; Cooper, C.; Diez Perez, A.; Eastell, R.; Hofbauer, L. C.; Kanis, J. A.; Langdahl, B. L.; Lesnyak, O.; Lorenc, R.; McCloskey, E. (2012-09-01). "A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis". Osteoporosis International. 23 (9): 2257–2276. doi:10.1007/s00198-012-1958-1. ISSN 1433-2965. PMID 22434203. S2CID 8745726.

• Skeletal disorders