Table of contents
Expand All Topics
Corticosteroid-induced osteoporosis
Background
Overview
Definition
Corticosteroids-induced osteoporosis is a form of secondary osteoporosis that is associated with the use of corticosteroids.
1
Pathophysiology
Corticosteroids-induced osteoporosis is characterized by increased bone loss secondary to direct and indirect effects of corticosteroids on bone remodeling.
2
Epidemiology
The annual incidence of vertebral and non-vertebral fractures in patients who initiated corticosteroids within the last 6 months is 5.1% and 2.5%, respectively. For patients on long-term corticosteroid therapy (≥ 6 months), the corresponding figures are 3.2% and 3.0%.
3
Disease course
Bone loss results from corticosteroid-mediated increases in expression of RANK ligand, which leads to increases in the number of bone-resorbing osteoclasts. Indirect effects of corticosteroids also include decreased renal calcium reabsorption, lower sex steroid hormone levels, in addition to increased PTH activity, which predispose patients to osteonecrosis and fractures.
2
4
Prognosis and risk of recurrence
The risk of fracture decreases by 29% after 2-6 months of corticosteroid discontinuation, and becomes similar to non-corticosteroid users by 12 months.
3
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of corticosteroid-induced osteoporosis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023) and the British Society for Haematology (BSH 2019).
1
2
3
4
5
6
Classification and risk stratification
Fracture risk assessment: as per ACR 2023 guidelines, obtain initial clinical fracture risk assessment including symptomatic and asymptomatic fracture history, FRAX score (age ≥ 40 only), and bone mineral density with vertebral fracture assessment or spine X-rays in all adult patients (≥ 18 years old) initiating or continuing corticosteroid therapy ≥ 2.5 mg/day for > 3 months.
A
Show 2 more
Medical management
Antiresorptive therapy, low fracture risk: as per ACR 2023 guidelines, do not initiate osteoporosis pharmacotherapy in ≥ 40 years old patients with low fracture risk because of the known risk of harm and no evidence of benefit.
D
More topics in this section
Antiresorptive therapy (moderate fracture risk)
Antiresorptive therapy (high or very high fracture risk)
Antiresorptive therapy (maintenance)
Management of treatment failure
Nonpharmacologic interventions
Calcium and vitamin D supplementation: as per ACR 2023 guidelines, consider optimizing dietary and supplemental calcium and vitamin D in addition to lifestyle modifications in adult and pediatric patients initiating or continuing chronic corticosteroid treatment at low, moderate, high, or very high fracture risk.
C
Specific circumstances
Pediatric patients
As per ACR 2023 guidelines:
Consider optimizing age-appropriate dietary and supplemental calcium and vitamin D in 4-17 years old pediatric patients with corticosteroids for > 3 months (low or moderate risk). Avoid initiating PO or IV bisphosphonates due to the low risk of osteoporotic fractures in this age group.
C
Consider initiating PO or IV bisphosphonates in 4-17 years old pediatric patients with an osteoporotic fracture continuing corticosteroid treatment at a dose of ≥ 0.1 mg/kg/day for > 3 months (high risk).
C
More topics in this section
Pregnant patients
Patients receiving high-dose corticosteroids
Patients with immune thrombocytopenia (fracture risk assessment)
Patients with immune thrombocytopenia (osteoporosis management)
Patients with immune thrombocytopenia (disease relapse)
Solid organ transplant recipients