Guideline outlines new approach to management of glucocorticoid-induced fractures

Pharmacological therapies may be appropriate for certain patients

In an update to 2010 recommendations, the American College of Rheumatology (ACR) provided the latest guidance on the assessment of risk, prevention, and treatment of fractures for adults and special populations undergoing long-term glucocorticoid (GC) treatment. The 2017 Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis (GIOP) made its debut in the August issue of Arthritis and Rheumatology.

While approximately 1% of Americans receive chronic GC therapy, more than 10% of these patients endure clinical fractures, and 30% to 40% show evidence of vertebral fractures. Factors contributing to increased risk include high daily and cumulative GC doses, long duration of treatment, low bone strength when beginning therapy, and a high rate of decline in bone mass during treatment.

Fortunately, GIOP is potentially reversible with proper management, and ACR outlined practices with which pharmacists may have a positive impact on patient care.

For patients at high to moderate risk of GIOP, pharmacologic therapies were recommended, taking into account cost, efficacy, toxicity, and patient preference. In order of preference, ACR suggested the following:

  • Oral bisphosphonates
  • I.V. bisphosphonates
  • Teriparatide (Forteo—Eli Lilly)
  • Denosumab (Prolia—Amgen)

With GC therapy, the highest rate of bone loss occurs within the first 3 to 6 months, then a slower decline continues with persistent use. Because of this rate, optimizing therapy from the start may result in a meaningful clinical impact.

The Guideline advised patients of all risk levels using GCs long-term to use calcium and vitamin D supplements. Lifestyle modifications to reduce risk of fracture in all patients included keeping a balanced diet, maintaining weight in the recommended range, quitting smoking, practicing regular weight-bearing or resistance training exercise, and limiting alcohol intake to one to two alcoholic beverages daily.

Recommendations indicated an initial fracture risk assessment within 6 months for anyone starting long-term GC treatment. While children required no further assessment, the Guideline endorsed bone mineral density (BMD) testing for adults younger than 40 years of age with history of an osteoporosis (OP)-related fracture or other significant OP risk factors. For adults aged 40 or older, ACR recommended BMD testing within 6 months of starting therapy as well as calculating the patient’s Fracture Risk Assessment Tool (FRAX) score. Adjustments to FRAX scores were outlined for those on doses equivalent to more than 7.5 mg per day of prednisone.

Patients younger than 40 years of age received a moderate-risk categorization if expecting to take more than 7.5 mg per day of GCs for 6 months and presenting with BMD Z scores of less than –3 or a decline in hip or spine BMD of 10% or more in 1 year of treatment. 

Reassessment of fracture risk involved a clinical reassessment every 12 months for everyone, with BMD testing every 2 to 3 years if younger than 40 years of age with high risk factors or 40 years of age or older and either receiving OP treatment alongside high risk factors or having completed OP treatment. Patients 40 years or older who have never received OP medication warranted updated FRAX scores and BMD testing every 1 to 3 years. 

For the full article, please visit www.pharmacytoday.org for the September 2017 issue of Pharmacy Today.