Review articleGlucocorticoid-induced osteoporosis☆
Section snippets
Epidemiology
Community surveys indicate that glucocorticoids are used by an estimated 0.2% to 0.5% of the general population [5], [6], [7]. Patients with RA, chronic obstructive pulmonary disease (COPD), asthma, and inflammatory bowel disease and transplant recipients comprise the majority of chronic glucocorticoid users internationally [6], [7].
During the first 6 to 12 months of glucocorticoid therapy, there is an initial rapid loss of 3% to 27% of bone mineral density (BMD) [8], [9], [10], [11], [12].
Pathogenesis
The etiology of GIOP is multi-factorial and occurs, in many cases, concomitantly with normal age and menopause-associated bone loss. There are two major pathways by which glucocorticoids lead to abnormalities in bone metabolism: (i) a reduction in bone formation and (ii) an increase in bone resorption [86], [87], [88]. Although the pathogenesis of GIOP is somewhat unsettled, a direct inhibition on osteoblast activity by glucocorticoids is the most favored principal mechanism [89], [90].
Diagnostic evaluation of the patient on glucocorticoids
There should be a high suspicion for potential bone loss among all patients initiating or chronically using glucocorticoids. The most accurate way to determine a glucocorticoid user's osteoporosis status is to assess bone mass, typically using dual-energy x-ray absorptiometry (DXA). Despite the precision of this approach and the vast benefits of DXA, the use of different DXA devices and disparities between the sites of measurement limit this technique [105]. If only a single site can be
Prevention and treatment
Based on this accumulating data showing an increased risk for bone loss among RA patients (particularly patients on steroids), there is a need to identify effective strategies aimed at mitigating possible toxicity. The American College of Rheumatology and other specialty groups have released recommendations for the prevention and treatment of GIOP [107], [108], [111], [112]. These recommendations advocate an increasingly aggressive approach to this serious problem based on accumulating
Treatment patterns and recommendations
Despite accumulating data on the effectiveness of anti-osteoporotic therapies in GIOP, only 5% to 35% of patients on glucocorticoids in the United States, Canada, and Great Britain receive therapies to prevent or treat GIOP [6], [7], [169], [170], [171], [172], [173], [174]. Although there are many reasons for this historically low use of GIOP interventions and for the significant practice pattern variation in GIOP management, it seems that symptomatic glucocorticoid toxicities, such as mood
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Supported in part by grant no. HS10389 from the Agency for Healthcare Research and Quality.