What is the recommended treatment for glucocorticoid-induced osteoporosis?

From the Guidelines

The recommended treatment for glucocorticoid-induced osteoporosis includes bisphosphonates as first-line therapy, particularly for adults aged 40 years or older at moderate to high risk of fracture, with oral bisphosphonates preferred due to their safety, cost, and lack of evidence of superior antifracture benefits from other osteoporosis medications 1. When initiating long-term glucocorticoid therapy (≥3 months) at doses equivalent to ≥5 mg prednisone daily, bisphosphonates should be started promptly, especially in high-risk patients such as postmenopausal women, men over 50, or those with previous fractures. Key considerations for treatment include:

• Optimizing calcium intake (1000-1200 mg daily) and vitamin D intake (600-800 IU daily) for all adults starting long-term glucocorticoid therapy 1
• Lifestyle modifications, including a balanced diet, maintaining a healthy weight, smoking cessation, regular weight-bearing or resistance training exercise, and limiting alcohol intake to 1-2 alcoholic beverages per day 1
• Regular bone mineral density monitoring every 1-2 years during treatment to assess effectiveness For patients who cannot tolerate oral bisphosphonates, alternatives may include:
• IV bisphosphonates, such as zoledronic acid (5 mg IV annually)
• Teriparatide (20 mcg subcutaneously daily for up to 24 months)
• Denosumab (60 mg subcutaneously every 6 months) However, these alternatives have a higher risk profile, cost, or lack of safety data in certain populations, making oral bisphosphonates the preferred first-line treatment 1. It is essential to note that the treatment approach may vary depending on the individual patient's risk factors, such as age, gender, and fracture history, as well as their ability to tolerate specific medications. The American College of Rheumatology guideline provides a comprehensive framework for the prevention and treatment of glucocorticoid-induced osteoporosis, emphasizing the importance of individualized treatment plans and regular monitoring to minimize the risk of fractures and optimize patient outcomes 1.

From the FDA Drug Label

1.4 Treatment of Glucocorticoid-Induced Osteoporosis Alendronate sodium tablets, USP are indicated for the treatment of glucocorticoid-induced osteoporosis in men and women receiving glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and who have low bone mineral density [see Clinical Studies (14.4)].

• The recommended treatment for glucocorticoid-induced osteoporosis is alendronate sodium tablets, USP in men and women receiving glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and who have low bone mineral density 2.

1.3 Treatment of Glucocorticoid-Induced Osteoporosis Prolia is indicated for the treatment of glucocorticoid-induced osteoporosis in men and women at high risk of fracture who are either initiating or continuing systemic glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and expected to remain on glucocorticoids for at least 6 months.

• Another recommended treatment for glucocorticoid-induced osteoporosis is denosumab (Prolia) in men and women at high risk of fracture who are either initiating or continuing systemic glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and expected to remain on glucocorticoids for at least 6 months 3.

From the Research

Treatment Options for Glucocorticoid-Induced Osteoporosis

The recommended treatment for glucocorticoid-induced osteoporosis (GIOP) includes:

• Bisphosphonate therapy as the current standard of care for prevention and treatment of GIOP 4
• Patient-specific treatment, with patients complying with a healthy lifestyle and receiving 1000 mg of calcium and at least 800 mg of Vitamin D daily 4
• Consideration of risk factors for involutional osteoporosis, such as older age, postmenopausal status, and baseline bone density measurements 5

Medications for GIOP

Medications that have shown benefit in treating GIOP include:

• Bisphosphonates, such as alendronate, risedronate, and zoledronate, which have demonstrated vertebral anti-fracture efficacy in postmenopausal women and men 4, 5
• Hormone replacement therapy and parathyroid hormone analogs, which are effective in preserving bone density in GIOP 5, 6
• Risedronate, which has been shown to be more useful for the prevention and treatment of GIOP in patients with rheumatoid arthritis than alfacalcidol 7

Prevention and Treatment Guidelines

Guidelines for the prevention and treatment of GIOP recommend:

• Non-pharmacological interventions, such as exercise and avoidance of tobacco and alcohol 6
• Supplemental calcium and vitamin D as first-line therapy 6
• Bisphosphonates, such as alendronate and risedronate, as first-line agents for GIOP 5, 6
• Preventative and curative therapy of GIOP should be maintained as long as the patient is on glucocorticoid treatment and could be stopped after weaning from glucocorticoid treatment 6