Providers and Patients Can Help Minimize Risks of Steroid-Induced Osteoporosis, ACR Says

New guidance from the American College of Rheumatology incorporates the latest osteoporosis medications and offers advice on sequential therapy to prevent rebound fractures.

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If you have to use steroids for pain from a chronic condition, a thoughtful treatment strategy may help you keep your bones stronger, longer.
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On September 14, 2022, the American College of Rheumatology (ACR) released a summary of updated guidelines (PDF) on how to manage glucocorticoid-induced osteoporosis (GIOP), a condition that can occur in people who take steroids as part of their treatment. The full manuscript is expected to be released in 2023.

The update comes five years after ACR’s 2017 recommendations and incorporates information on more recent osteoporosis treatments, namely Tymlos (abaloparatide) and Evenity (romosozumab), as well as recommendations for sequential therapy to prevent rebound fractures.

Steroids Relieve Symptoms, Treat Many Conditions, but Can Increase Osteoporosis Risk

Glucocorticoids (GCs) can relieve the inflammation and pain common in rheumatic diseases such as rheumatoid arthritis (RA) as well as other chronic conditions, including multiple sclerosis (MS), Crohn’s disease, ulcerative colitis (UC), psoriasis, atopic dermatitis, allergies and asthma, and heart failure.

RELATED: 8 Great Pain Relievers You Aren't Using

Although GCs are a valuable tool, treatment guidelines typically emphasize the need to use steroids more sparingly due to concerns about safety and potential side effects. In cases where the treatment is longer term or steroids are used in higher doses, the risk of osteoporosis becomes a concern.

Long-Term Use of Steroids Weaken Bones, Increase Chance of Fracture

“Glucocorticoid excess is detrimental to bone mineral density and bone quality which leads to increased fracture risk,” says Katherine Wysham, MD, assistant professor of rheumatology at UW School of Medicine in Seattle. That’s because steroids tend to reduce the body’s ability to absorb calcium, and at the same time it increases how fast bone is broken down.

How Much Steroid Use Is Considered Long-Term – and Risky?

Oral steroid at a dose equal to or more than 5 mg of prednisone daily taken for more than three months are considered a risk for fracture, and the risk increases as the daily dose of steroids increases, according to the New York State Osteoporosis Prevention and Education Program (NYSOPEP). Bone loss occurs most rapidly in the first six months after starting oral steroids; after 12 months of chronic steroid use, there is a slower loss of bone, according to NYSOPEP.

Compared with oral steroids, inhaled steroids are less likely to cause bone loss.

Steroids used for only a few days or applied topically in the form of a cream or ointment are not associated with bone loss.

It’s estimated that fractures occur in as many as 50 percent of long-term steroid users, according to a study published in Endocrinology and Metabolism Clinics of North America. Even doses as low as 2.5 mg of prednisolone a day may increase the risk of fracture, per research.

Fracture Risk Assessment Is Recommended as Soon as Steroid Therapy Starts

Once steroid therapy is started, fracture risk should be assessed as soon as possible, at least within six months after starting, and then annually after that, per an article published in 2021 in Open Access Rheumatology. Other risk factors can include:

  • History of falls or fractures
  • Low body weight or malnutrition
  • Alcohol use
  • Smoking

People with risk factors for osteoporosis (in addition to glucocorticoid therapy use) should be considered for stronger antiresorptive or anabolic therapies to reduce fracture risk, and sequential therapy may be necessary, says Bart Clarke, MD, endocrinologist and professor of medicine at Mayo Clinic in Rochester, Minnesota.

Fracture Risk Drops When Steroids Are Discontinued

The good news is that once steroids are discontinued, the risk of fracture rapidly decreases, according to research published in The New England Journal of Medicine.

A large retrospective study published in Osteoporosis International showed an increased risk of a major osteoporotic fracture among people who took steroids for longer than three months within the past year, but not among people with intermittent or past use (more than one year prior) of steroids.

What Is Sequential Therapy?

Sequential therapy begins with one medication, and then switches to another medication after a time. The sequence allows for greater increase in bone density than therapy with just one medication and helps retain the gains in bone mass and bone strength.

How to Prevent, Treat Steroid-Induced Bone Loss

If you have RA, Crohn’s, eczema, or one or more of the countless conditions that may be managed with steroids, you will want to understand how to reduce bone loss and fracture risks.

Sequential Therapy Can Reduce Fracture Risk in People With GCOP

Tymlos (abaloparatide) and Evenity (romosozumab) have been welcome additions to the treatment options for people with osteoporosis, says Dr. Wysham. These are considered anabolic therapies which build new bone, improve bone density, and help prevent fracture, she says. Antiresorptive medications prevent bone loss and may increase bone density.

These two new osteoporosis therapies reduce fracture risk more than previously available therapies, and they have a rapid onset and offset of action, says Dr. Clarke. Forteo (teriparatide), an osteoporosis treatment drug approved in 2002, also works by building bone.

Using bisphosphonate after stopping anabolic agents can prevent rapid bone loss that will otherwise occur, and the accompanying increased fracture risk, he says.

In some cases, the bone loss drug Prolia (denosumab) may be used after patients have completed a course of Tymlos or Evenity.

Sequential therapy is also recommended when using Prolia (denosumab) and Forteo (teriparatide), which are also associated with excessive BMD loss and increased fracture risk after discontinuation.

“Through emphasizing sequential therapy, the GIOP guideline update highlights the importance of having a treatment course mapped out for each patient which involves an exit-strategy for any medication requiring additional therapy upon discontinuation,” says Wysham.

Updated Guidelines Encourage Shared Decision Making Between Provider and Patient

The new guidelines reflect the reality of clinical care for patients with osteoporosis, says Clarke. “More clinical trial data has become available over the last five years to help guide clinical therapy. Studies indicate that some drugs work better than others, and that sometimes one drug is not enough,” he says. While the newer medications are more potent, they still work best with sequential therapy.

“Rather than weigh in on what medication is best for each fracture risk category, the updated GIOP guideline emphasize shared decision making between the patient and their prescribing practitioner. This supports individualization of treatment options, which is good for patient care,” says Wysham.