The British Society for Haematology has released new recommendations on the clinical management of osteoporosis secondary to glucocorticoid use in patients with immune thrombocytopenia.
The “good practice paper” was published in the British Journal of Haematology.
“Glucocorticoids are a standard first-line treatment for immune thrombocytopenia and are an important risk factor for osteoporosis,” wrote Quentin A. Hill, MBChB, of the University of Leeds (England), and his colleagues.
When given for extended periods of time, glucocorticoids have been shown to trigger substantial reductions in bone mineral density, which has been linked with an increased risk for bone fractures. The researchers reported that fracture risk is not exclusively dependent on steroid use but is also affected by other factors, such as patient age, duration of glucocorticoid use, and treatment dose.
“Some studies have found that fracture risk is not significantly elevated in patients receiving oral glucocorticoids for [less than] 3 months,” the researches wrote. “Most guidelines are for patients with an intended duration of treatment [greater than] 3 months.”
In adult patients treated with glucocorticoids, the authors recommended that appropriate educational information be provided on how to enhance bone health. Additionally, they stated that patients should obtain sufficient calcium and vitamin D, defined as 700-1,200 mg and 800 IU daily, respectively, which can be achieved through diet or supplementation.
“Patients at high risk of fracture should be considered for oral alendronate or risedronate,” they wrote. “If contraindicated or poorly tolerated, zoledronic acid, denosumab, or teriparatide are appropriate alternatives.”
With respect to the use of glucocorticoids for relapse, the experts recommended starting on the lowest effective dose and providing steroid-sparing agents when appropriate. Treatment with bisphosphonates may benefit children and patients aged less than 40 years.
The authors also reported that glucocorticoid cessation may reduce some degree of fracture risk; however, an elevated risk does remain, even after withdrawal of therapy, warranting ongoing clinical assessment and follow-up.
Dr. Hill and several coauthors reported financial affiliations with Amgen, Novartis, Ono Pharmaceuticals, Shire, and others.
SOURCE: Hill QA et al. Br J Haematol. 2019 Jan 4. doi: 10.1111/bjh.15735.