The American College of Rheumatology (ACR) released updated guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP). The full recommendations were published in Arthritis Care & Research.
This updated guideline, covering the period from April 23, 2016, to January 24, 2022, incorporated two newly-approved medications for osteoporosis — abaloparatide (ABL) and romosozumab (ROM) — along with information on combination and sequential therapies introduced after the 2017 guideline. fatty lipoma removal
To create clinical questions, review authors utilized the Patient, Intervention, Comparison, and Outcomes format.
A diverse team of experts conducted a comprehensive literature review and risk-benefit analysis of recently approved treatments for osteoporosis, adhering to recommendations for patient risk stratification.
To assess the accuracy of the literature, experts used the Grading of Recommendations Assessment, Development and Evaluation methodology.
An expert voting panel and patient panel collaborated to determine the direction and strength of each recommendation.
Recommendation #1: In adults starting or continuing glucocorticoid (GC) therapy at a dose of at least 2.5 mg/day for over 3 months, the ACR strongly recommends an initial clinical fracture risk assessment. This should include symptomatic and asymptomatic fracture history, use of the Fracture Risk Assessment Tool (FRAX) in individuals aged 40 years or older, and bone mineral density (BMD) with vertebral fracture assessment (VFA) or spinal x-rays, as opposed to not conducting any assessment.
Per the 2022 update, akin to the 2017 guidelines, individuals with GIOP should still undergo risk stratification for major osteoporotic fracture (MOF) into the following:
– Low Risk: less than 10% probability of MOF
– Moderate Risk: 10% to 19% probability of MOF
– High Risk: at least 20% probability of MOF
– Very-High Risk: at least 30% probability of MOF
All adult patients on GCs are recommended to maintain sufficient age-appropriate intake of calcium and vitamin D, engage in weight-bearing exercise, and refrain from smoking and excessive alcohol consumption.
The ACR strongly recommends osteoporosis treatment for individuals at moderate, high, or very-high risk for fracture.
Table: Treatment Recommendations Based on Fracture Risk
Recommendation #1: For adults taking chronic GC doses between 2.5 mg/day and less than 7.5 mg/day who have a low fracture risk and are not recommended to start therapy, or those with moderate fracture risk who choose not to initiate osteoporosis therapy (besides calcium and vitamin D), the ACR strongly recommends reassessing fracture risk every 1 to 2 years.
-History of fractures and new fractures
Recommendation #2: For adults receiving chronic GC therapy at doses of at least 2.5 mg/day considered to be at moderate, high, or very-high risk for fracture who have maintained osteoporosis therapy for at least 1 year, the ACR strongly recommends reassessing fracture risk every 1 to 2 years, as opposed to not reassessing the risk.
-Consideration of yearly BMD assessment until stability is achieved, specifically for individuals at very-high fracture risk.
Recommendation #3: For adults discontinuing GCs but remaining at moderate, high, or very-high risk for fracture, the ACR strongly recommends the continuation of osteoporosis therapy.
Recommendation #1: For individuals of all ages (adults and children) who are initiating or continuing long-term GC therapy at a dose of at least 2.5 mg/day for greater than 3 months, the ACR conditionally recommends considering the optimization of age-appropriate dietary and supplemental intake of calcium and vitamin D, in conjunction with making lifestyle modifications.
-Adults: dietary/supplemental elemental calcium intake of 1000 to 1200 mg daily
-Children: dietary/supplemental elemental calcium intake of 1000 to 1300 mg daily, depending on age
-Vitamin D supplementation to sustain serum vitamin D 25(OH)D levels of at least 30 to 50 ng/mL, typically requiring 600 to 800 international units daily or further supplementation as needed
-Lifestyle modifications: balanced diet, regular weight-bearing/resistance training exercises, cessation of smoking, and decreasing alcohol intake to 2 or fewer servings daily
Recommendation #2: For adults aged at least 40 years facing high or very-high fracture risk, the ACR strongly recommends osteoporosis therapy instead of relying solely on calcium and vitamin D treatment.
Recommendation #3: For adults aged at least 40 years facing high fracture risk, the ACR conditionally recommends PTH/PTHrP over antiresorptives.
Recommendation #4: For adults aged at least 40 years facing high or very-high fracture risk, the ACR strongly recommends oral BP over no treatment.
Recommendation #5: For adults aged at least 40 years facing high fracture risk, the ACR conditionally recommends PTH/PTHrP or DEN over BP.
Recommendation #6: For adults aged at least 40 years facing high fracture risk, the ACR conditionally recommends IV or oral BP, PTH/PTHrP, or DEN over RAL or ROM.
Recommendation #7: For adults aged at least 40 years facing high or very-high fracture risk, the ACR conditionally recommends against the use of multiple osteoporosis therapies concurrently.
Recommendation #8: For adults of all ages facing moderate fracture risk, the ACR conditionally recommends oral or IV BP, PTH/PTHrP, or DEN over no treatment.
Recommendation #9: For adults of all ages facing moderate fracture risk, the ACR conditionally recommends against ROM and RAL therapies, except among those intolerant of other osteoporosis medications, due to potential life-threatening harms.
Recommendation #10: For adults of all ages facing low fracture risk, the ACR strongly recommends against adding oral or IV BP, PTH/PTHrP, RAL, DEN, or ROM.
Recommendation #1: For adults aged at least 40 years facing very-high fracture risk due to treatment with high-dose GC therapy, the ACR conditionally recommends treatment with PTH/PTHrP over antiresorptive agents, regardless of FRAX score or BMD.
Additionally, the ACR strongly recommends oral BP and conditionally recommends the use of IV BP, DEN, RAL, or ROM over no treatment, among this patient population.
Recommendation #2: For adults aged less than 40 years being treated with high-dose GC therapy, the ACR conditionally recommends oral or IV BP, PTH/PTHrP, or DEN.
Additionally, the ACR conditionally recommends against using RAL and ROM as therapeutic options among this patient population.
Recommendation #3: For patients facing moderate or high fracture risk who can become pregnant, the ACR conditionally recommends oral or IV BP, DEN, or PTH/PTHrP.
Recommendation #4: For patients with solid organ transplants with an estimated glomerular filtration rate of at least 35 mL/min who are on chronic GC treatment, the ACR conditionally recommends considering BP, DEN, PTH/PTHrP, or RAL based on patient-specific factors rather than opting for no treatment.
Additionally, the ACR conditionally recommends against using ROM as a therapeutic option among this patient population.
Recommendation #5: For adult patients who have received a renal transplant undergoing long-term GC treatment, the ACR conditionally recommends considering an evaluation by a specialist to assess for the presence of chronic kidney disease-mineral and bone disorder.
Recommendation #6: For children aged 4 to 17 years facing low or moderate fracture risk being treated with GCs for more than 3 months, the ACR conditionally recommends abiding by Recommended Daily Allowance guidelines for dietary/supplementation of calcium and vitamin D.
Additionally, the ACR conditionally recommends against initiating oral or IV BP among this patient population.
Recommendation #7: For children aged 4 to 17 years facing high fracture risk with a history of osteoporotic fracture who are taking GCs at a dose of at least 0.1 mg/kg/day for longer than 3 months, the ACR conditionally recommends treatment with oral/IV BP.
Recommendation #1: For adults undergoing GC treatment who have experienced an osteoporotic fracture 12 months or more after starting osteoporosis therapy (eg. oral BP), or have encountered a substantial loss of BMD after 1 to 2 years of osteoporosis treatment, the ACR conditionally recommends switching to an alternative class of osteoporosis medication (eg. IV BP, DEN, ROM, or PTH/PTHrP).
Recommendation #1: For adults undergoing osteoporosis therapy who are discontinuing GC treatment, provided they have not experienced any new fragility fractures and currently have a BMD t-score of at least -2.5, the ACR strongly recommends ceasing the current osteoporosis therapy and instead continuing with calcium and vitamin D supplementation.
After discontinuation of DEN, PTH/PTHrP, and ROM, the ACR strongly recommends sequential therapy.
Recommendation #2: For adults aged at least 40 years discontinuing GC therapy and remaining at high fracture risk (BMD t-score ≤-2.5 or history of fragility fracture ≥12 months into therapy), the ACR conditionally recommends continuing current osteoporosis therapy or transitioning to another class of osteoporosis medication.
-Initial osteoporosis treatment → Recommended alternative
Recommendation #3: For adults aged at least 40 years undergoing long-term GC therapy and discontinuing DEN, the ACR strongly recommends initiating an antiresorptive treatment instead of abstaining from osteoporosis medications.
Recommendation #4: For adults aged at least 40 years who have completed a course of PTH/PTHrP and are discontinuing chronic GC treatment, the ACR conditionally recommends initiating BP instead of opting for no osteoporosis treatment.
Recommendation #1: For all adults discontinuing GC treatment who face low fracture risk with no new fragility fracture and have a current BMD t-score greater than -2.5, the ACR conditionally recommends the following sequential treatment options:
-Initial osteoporosis treatment → Recommended alternative
Recommendation #2: For all adults discontinuing GC treatment who face high or very-high fracture risk with a fragility fracture occurring after at least 12 months of osteoporosis therapy and a BMD t-score of -2.5 or less, the ACR conditionally recommends continuing current therapy or switching to IV BP, DEN, PTH/PTHrP, or ROM.
Guideline authors concluded, “This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.”
Humphrey MB, Russell L, Danila MI, et al. 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). Published online October 26, 2023. doi: 10.1002/acr.25240
Latest News Your top articles for Wednesday
Haymarket Medical Network Top Picks
Continuing Medical Education (CME/CE) Courses
Please login or register first to view this content.
Copyright © 2024 Haymarket Media, Inc. All Rights Reserved. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Your use of this website constitutes acceptance of Haymarket Media’s Privacy Policy and Terms & Conditions.
Enjoying our content? Thanks for visiting Rheumatology Advisor. We hope you’re enjoying the latest clinical news, full-length features, case studies, and more.
You’ve viewed {{metering-count}} of {{metering-total}} articles this month. If you wish to read unlimited content, please log in or register below. Registration is free.
Log in to continue reading this article.
Don’t miss out on today’s top content on Rheumatology Advisor. Register for free and gain unlimited access to:
- Clinical News, with personalized daily picks for you - Case Studies - Conference Coverage - Full-Length Features - Drug Monographs - And More
malignant pheochromocytoma Please login or register first to view this content.