Identifying patients at risk for fractures due to chronic steroids
As a clinical pharmacist, it is important to address the therapy gap in preventing osteoporosis and fractures among patients on chronic corticosteroids. More than one in 10 patients using these medications long-term will experience a fracture as a result of glucocorticoid-induced osteoporosis. It is crucial for you as a pharmacist to be vigilant in identifying patients on chronic corticosteroids and take steps to minimize their risk of fractures. For further information, see note on "Screening and management of osteoporosis".
Emphasize prevention early since bone density drops the most during the first 3 to 6 months of using an oral steroid. Advise getting daily calcium 1,000 to 1,200 mg plus vitamin D 600 to 800 IU from diet and supplements, plus weight-bearing exercise. Identify men and women with fracture risks especially those age 50 and older taking prednisone 5 mg/day or more for 3 months or longer, or possibly those who get 3 or more steroid bursts in 6 months. Also look for steroid patients with other risks, low body weight, smoking, excessive alcohol use, hip fracture in a parent, etc. But fracture risk is low in patients only using an inhaled steroid. Consider using the FRAX fracture risk assessment tool in patients age 40 or older to quickly estimate 10-year fracture risk.
Suggest medications for high-risk patients, those on chronic steroids who have a prior fracture due to low bone density, a low T-score, or a FRAX score above 1% for hip fracture or 10% or above for any fracture. Use an approach similar to managing osteoporosis. Get our note "Approach to osteoporosis".
Recommend oral alendronate or risedronate in most cases. There's little evidence for using ibandronate in steroid-induced osteoporosis. If patients can't take an oral medication, lean toward once-yearly IV Reclast (zoledronic acid) or twice-yearly subcutaneous Prolia (denosumab). Or consider Forteo (teriparatide) for patients with prior fractures or a very low T-score, but it's a daily subcutaneous injection and can only be used for up to 2 years due to concerns about osteosarcoma. Usually suggest taking medications for up to 5 years. But be aware some very high-risk patients may continue as long as the steroid is needed.
References
- Buckley L, Guyatt G, Fink HA, et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol. 2017;69(8):1521-1537.
- Allen CS, Yeung JH, Vandermeer B, Homik J. Bisphosphonates for steroid-induced osteoporosis. Cochrane Database Syst Rev. 2016;10(10):CD001347.
