Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in adults: Recommendations From the European Calcified Tissue Society

Abstract Introduction This report presents the recommendations of the European Calcified Tissue Society (ECTS) for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) in adults. Our starting point was that the recommendations be evidence based, focused on non-bone specialists who treat patients with GC and broadly supported by ECTS. Methods The recommendations were developed by global experts. After a comprehensive review of the literature, twenty-five recommendations were formulated, based on quality evidence. For stratifying fracture risk and the most appropriate first line of treatment, we have classified patients into 3 categories: those at medium risk of fractures i.e. adults without a recent (in the last 2 years) history of fracture, those at high risk of fractures i.e. adults with recent history of fracture, and/or at least one vertebral fracture (grade ≥ 2 according to Genant classification), and those at very high risk of fractures i.e. adults aged ≥ 70 years with a recent hip fracture, pelvis fracture, and/or at least one vertebral fracture (grade ≥ 2 according to Genant classification) . The subtopics in the recommendations include Who to assess, How to assess, Who to treat, How to treat, and Follow-up and Monitoring. Results General measures are recommended for all patients who are being prescribed glucocorticoids (GCs) for > 3 months: i.e. calcium and protein intake should be normalized, a 25(OH) vitamin D concentration of 50-125 nmol/L should be attained, and the risk of falls be minimized. 1)Who to assess? (R1-2) A preliminary assessment of fracture risk should be routinely performed in patients likely to receive oral GCs for ≥ 3 months: (i) women and men ≥ 50 years and (ii) patients at increased risk of fracture (history of fragility fracture and/or have comorbidities or are on medications that are frequently associated with osteoporosis. 2)How to assess (fracture risk)? (R3-6) Clinical risk factors including history of fragility fracture, systematic vertebral imaging, and GCs dose-adjusted FRAX, measurement of BMD by DXA, fall risk, and biochemical testing. 3) Who to treat? (R7-12) Anti-osteoporosis treatment is indicated for women and men ≥ 50 years with (i) the presence of a recent history of vertebral and/or non-vertebral fracture (less than 2 years) (ii)and/or a GCs dosage ≥ 7.5 mg/day, (iii)and/or age ≥ 70 years (iv)and/or a T-score ≤ -1.5, (v)and/or 10-year probability risk above the country specific GC dose-adjusted FRAX® thresholds. In premenopausal women and men < 50 years with a Z-score ≤ -2 and/or a history of fragility fracture, it is recommended to refer the patient to a bone specialist. 4) How to treat? (R13-18) In women and men ≥ 50 years, (i) alendronate or risedronate is preferred as the first line of treatment in patients at medium risk of fractures, (ii) zoledronic acid or denosumab in patients at high risk of fractures, and (iii) teriparatide in patients at very high risk of fractures. It is imperative that sequential therapy be implemented in individuals receiving denosumab or teriparatide as their first-line treatment regimen. 5) Follow-up and Monitoring (R19-25): In patients receiving anti-osteoporosis treatment, monitoring of clinical risk factors (e.g., history of fragility fracture), systematic vertebral imaging, fall risk, BMD measurement using DXA, and biochemical testing should be performed regularly during follow-up. Conclusions The new, evidence-based recommendations by the ECTS for the prevention and treatment of GIOP provide clear and pragmatic advice to all health practitioners especially those who are not bone specialists.