SANTA BARBARA, CALIF. — About half of patients using glucocorticoids for long periods will suffer compression fractures of the vertebrae if nothing is done to intervene, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.
Bisphosphonate therapy is clearly effective in reducing fractures, whether started when initiating glucocorticoids or after a patient has been on them for a while. But bisphosphonates aren't enough, and other steps should be taken to manage these patients, said Dr. Lukert of the University of Kansas Medical Center in Kansas City.
Other opportunities to intervene include:
▸ Diet is critical. Since glucocorticoids are catabolic, patients need adequate protein intake, not just calcium and phosphorus.
▸ Heavily encourage patients to exercise, not only because of its benefits on bone. Glucocorticoids often cause myopathy, ranging from mild to severe, and exercise can stave this off. Strengthening the quadriceps and related muscle groups has been shown to prevent falls.
▸ Control urinary calcium. A very large percentage of patients on glucocorticoids will develop hypercalciuria, and restricting sodium in the diet will go a long way toward resolving this.
▸ Replace hormones as appropriate. Glucocorticoids inhibit pituitary gonadotropin, and men taking steroids often have low testosterone levels. If there's no contraindication, this testosterone should be replaced, Dr. Lukert said.
Women taking steroids often have low estrogen levels. If premenopausal women become amenorrheic on glucocorticoids, consider prescribing estrogen or progesterone. Dr. Lukert noted that estrogen replacement in postmenopausal women remains controversial.
Patients who have a bone mineral density (BMD) T score of less than −1.5 or are taking more than 10 mg/day of prednisone or the equivalent should receive bisphosphonate therapy as soon as corticosteroids are started.
Patients with a higher BMD taking lower doses of prednisone may hold off on starting bisphosphonate therapy at first and retest BMD after 6 months.
Another reasonable strategy is simply to give a bisphosphonate to all patients who anticipate taking steroids for several weeks or longer.
This strategy is certain to prevent fractures, but at the cost of treating 40%–50% of patients who would not have suffered a fracture even without the bisphosphonate prescription, Dr. Lukert said.