PARK CITY, UTAH — Patients with immunobullous disease who are on systemic glucocorticoids require monitoring for bone loss and supportive interventions to prevent drug-induced osteoporosis, Dr. Kim B. Yancey told physicians at a clinical dermatology seminar sponsored by Medicis.
Glucocorticoid-induced osteoporosis primarily affects trabecular bone, he said, labeling the problem as “especially prominent” in children, adolescents, and postmenopausal women. Other adverse effects include osteonecrosis, primarily in the hip, and impairment in bone growth. He described the underlying mechanism as biologic.
The standard glucocorticoid therapy for patients with autoimmune blistering diseases starts at 1 mg/kg per day of oral prednisone. For patients requiring more aggressive treatment, Dr. Yancy, chairman of dermatology and codirector of the cutaneous immunopathology laboratory at the Medical College of Wisconsin in Milwaukee, recommended higher doses of oral prednisone plus 1 g/day of pulse methylprednisolone for 3–5 days.
Pemphigus and pemphigoid patients starting on long-term steroids should also be instructed to take 1,200–1,500 mg of elemental calcium daily and 400 IU of vitamin D twice a day. He recommended a low-sodium diet as well.
Later, after patients have started to benefit from the regimen, he advocated prescribing bisphosphonates and encouraging patients to do simple weight-bearing exercises.
“The main thing is to try to get patients to walk,” which is easier when they are not in severe pain, he said.
Dr. Yancey noted that taking medications associated with low bone mass or bone loss is an indication for bone mineral absorptiometry. He recommended ordering this test of bone density at baseline and 1 year.
For patients who have a notable history of renal stones or otherwise need to have urinary calcium levels monitored, he advocated calling in a consultant. He also suggested requesting a consultation in decisions regarding sex hormone replacement therapy (HRT) for men or women, thiazide diuretics, and calcitonin in patients who do not tolerate bisphosphonates or who have pain from compression fractures. When prescribing corticosteroids, physicians should also consider drug interactions. Some agents, such as azole antifungals and macrolide antibiotics, increase corticosteroid levels and toxicity.