Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis

Abstract

Background: To develop guidelines and recommendations to prevent and treat glucocorticoid (GC)-induced osteoporosis (GIOP) in Korea.

Methods: The Korean Society for Bone and Mineral Research and the Korean College of Rheumatology have developed this guideline based on Guidance for the Development of Clinical Practice Guidelines ver. 1.0 established by the National Evidence-Based Healthcare Collaborating Agency. This guideline was developed by adapting previously published guidelines, and a systematic review and quality assessment were performed.

Results: This guideline applies to adults aged ≥19 years who are using or plan to use GCs. It does not include children and adolescents. An initial assessment of fracture risk should be performed within 6 months of initial GC use. Fracture risk should be estimated using the fracture-risk assessment tool (FRAX) after adjustments for GC dose, history of osteoporotic fractures, and bone mineral density (BMD) results. All patients administered with prednisolone or an equivalent medication at a dose ≥2.5 mg/day for ≥3 months are recommended to use adequate calcium and vitamin D during treatment. Patients showing a moderate-to-high fracture risk should be treated with additional medication for osteoporosis. All patients continuing GC therapy should undergo annual BMD testing, vertebral X-ray, and fracture risk assessment using FRAX. When treatment failure is suspected, switching to another drug should be considered.

Conclusions: This guideline is intended to guide clinicians in the prevention and treatment of GIOP.

Keywords: Bisphosphonate; Denosumab; Glucocorticoids; Osteporosis; Teriparatide.

Fig. 1. Flowchart of the systematic search of literature and selection process for the development of glucocorticoid-induced osteoporosis by adaptation.

Fig. 2. Initial fracture risk assessment. A clinical fracture risk assessment includes obtaining a history with the details of GC use (dose, duration, pattern of use), an evaluation for falls, fractures, frailty, and other OP risk factors (malnutrition, significant weight loss or low body weight, hypogonadism, secondary hyperparathyroidism, thyroid disease, family history of hip fracture, history of alcohol use [at ≥3 units/day] or smoking) and other clinical comorbidities, and a physical examination including measurement of weight and height (without shoes), testing of muscle strength, and assessment for other clinical findings of undiagnosed fracture (i.e., spinal tenderness, deformity, and reduced space between lower ribs and upper pelvis) as appropriate given the patient's age. The risk of major osteoporotic fracture calculated with the fracture-risk assessment tool (FRAX) should be increased by 1.15, and the risk of hip fracture by 1.20, if the prednisone dose is 7.5 mg/day (i.e., if the calculated hip fracture risk is 2.0%, increase to 2.4%). It is recognized that in some cases, BMD testing may not be available. GC, glucocorticoid; OP, osteoporosis; BMD, bone mineral density. [Reprinted from “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.”, by Buckley L, et al., 2017, Arthritis Care Res (Hoboken), 69, pp.1095–1110. Copyright 2017 by the Wiley. Reprinted with permission].

Fig. 3. Reassessment of fracture risk. A clinical fracture risk assessment includes obtaining a history with the details of GC use (dose, duration, pattern of use), an evaluation for falls, fractures, frailty, and other OP risk factors (malnutrition, significant weight loss or low body weight, hypogonadism, secondary hyperparathyroidism, thyroid disease, family history of hip fracture, history of alcohol use [at ≥3 units/day] or smoking) and other clinical comorbidities, and a physical examination including measurement of weight and height (without shoes), testing of muscle strength, and assessment for other clinical findings of undiagnosed fracture (i.e., spinal tenderness, deformity, and reduced space between lower ribs and upper pelvis) as appropriate given the patient's age. Very high-dose GC treatment was defined as treatment with prednisone ≥30 mg/day and a cumulative dose of 5 g in the past year. Reliability of fracture-risk assessment tool (FRAX) after OP treatment is debated, but FRAX calculation can be repeated in adults age ≥40 years who have not received treatment. It is recognized that in some cases, BMD testing may not be available. GC, glucocorticoid; OP, osteoporosis; BMD, bone mineral density. [Reprinted from “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.”, by Buckley L, et al., 2017, Arthritis Care Res (Hoboken), 69, pp.1095–1110. Copyright 2017 by the Wiley. Reprinted with permission].

Fig. 4. Initial pharmacologic treatment for adults. Recommended doses of calcium and vitamin D are 1,000 to 1,200 mg/day and 600 to 800 IU/day (serum level ≥20 ng/mL), respectively. Lifestyle modifications include a balanced diet, maintaining weight in the recommended range, smoking cessation, regular weight-bearing and resistance training exercise, and limiting alcohol intake to 1 to 2 alcoholic beverages/day. Very high-dose GC treatment was defined as treatment with prednisone ≥30 mg/day and a cumulative dose of >5 g in the past year. The risk of major OP fracture calculated with the fracture-risk assessment tool (FRAX) should be increased by 1.15, and the risk of hip fracture by 1.2, if the prednisone dose is >7.5 mg/day (i.e., if the calculated hip fracture risk is 2.0%, increase to 2.4%). It is recognized that in some cases, BMD testing may not be available. BMD, bone mineral density; OP, osteoporosis; GC, glucocorticoid; SERM, selective estrogen receptor modulating agent. [Reprinted from “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.”, by Buckley L, et al., 2017, Arthritis Care Res (Hoboken), 69, pp.1095–1110. Copyright 2017 by the Wiley. Reprinted with permission].