Arthritis Facts
Steroids and Osteoporosis Prevention
Since the introduction of glucocorticoids (GC) in 1949, their use has become widespread in the treatment of multiple inflammatory disorders. These include inflammatory diseases such as arthritis, asthma, skin diseases, autoimmune disorders and organ transplantation. Treatment with GCs can be complicated by many side effects. One of the most common toxicities is osteoporosis. Although bone loss is initially asymptomatic, osteoporosis and fractures are the most common cause of serious long-term morbidity. There are many therapies now available to reduce or prevent these associated side effects.
The initial phase of GC treatment results in rapid bone loss of as much as 10%-30% in trabecular bone. Accelerated bone loss may occur even in patients on low dose regimens. Loss is usually greatest in the spine and ribs causing a threefold to fourfold increase in vertebral fracture rates. The bone loss is related to the dose and duration of the GC treatment.
Primary prevention is of paramount importance since the bone loss starts in the first three to six months of therapy. Your doctor will always attempt to choose the lowest dose of steroid use possible. Inhaled or topical therapy is always preferred if possible. Baseline Bone Density measurements will be taken and potentially assessed every six months to two years as necessary. Calcium and vitamin D play an important role in prevention. The American College of Rheumatology recommends 1500 mg/day of calcium and Vitamin D intake of 400-800 IU/day.
Biphosphonates are potent agents that inhibit bone loss. These include Didronel, Fosamax and Actonel. Calcitonin may also be helpful in the overall treatment and prevention. The data on hormone replacement therapy is still unclear as to its ultimate effectiveness. Newer therapies may include human parathyroid hormone treatment.
Recommendations
Patients taking more than 5-7.5 mg/day of prednisone or any equivalent GC for more than 3-6 months should be considered for preventive therapy. All patients should receive adequate calcium and vitamin D treatment. Hormonal replacement may be considered for postmenopausal women. Bone mineral density measurement should be performed baseline and periodically to assess therapy. Consideration should be made for the addition of a biphosphonate medication as additional preventive treatment.