What are the considerations for steroid use in a patient with osteoarthritis and spinal stenosis, who also has Parkinson's disease and is HIV-positive on Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide)?

Steroid Use in Osteoarthritis and Spinal Stenosis with Parkinson's Disease and HIV on Biktarvy

Direct Recommendation

Corticosteroids should be used with extreme caution and only for short-term, limited interventions in this patient, given the significantly elevated risk of avascular necrosis and osteoporosis in HIV-positive individuals, particularly when combined with existing bone health risks from antiretroviral therapy. 1

Critical Risk Assessment

Avascular Necrosis Risk

• Corticosteroid use is directly linked to avascular necrosis (AVN) in HIV-positive patients, with corticosteroids identified as a major independent risk factor regardless of antiretroviral regimen 1, 2
• HIV infection itself increases AVN risk, and the combination of HIV plus corticosteroids creates a synergistic risk profile 1, 3
• AVN most commonly affects the hips and spine—precisely the anatomical areas this patient needs treated for spinal stenosis 1, 3
• Approximately 5% of HIV patients have asymptomatic AVN detectable on MRI, indicating subclinical disease may already be present 1

Bone Density Concerns

• HIV-positive patients on antiretroviral therapy have significantly increased rates of osteopenia (up to 50%) and osteoporosis 1
• Baseline bone densitometry (DXA) should be performed before any corticosteroid use to assess current bone health status 1, 4
• Corticosteroids decrease bone formation and increase bone resorption, compounding the bone loss already occurring from HIV and antiretroviral therapy 5

Biktarvy-Specific Considerations

• Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) has demonstrated favorable bone safety profiles with minimal bone mineral density changes (≤0.6% at hip and spine) over 5 years 6
• Tenofovir alafenamide in Biktarvy causes less bone loss than older tenofovir formulations, but corticosteroids would still add independent bone-damaging effects 7, 6
• No significant drug-drug interactions exist between Biktarvy and corticosteroids, so dose adjustments of antiretroviral therapy are not required 7

Treatment Algorithm for This Patient

First-Line Approach (Avoid Systemic Steroids)

• For osteoarthritis: Intra-articular corticosteroid injections provide 1-3 weeks of benefit and are preferable to systemic steroids if joint-specific treatment is needed 8
• For spinal stenosis: Epidural steroid injections (ESI) can be considered, with repeat injections at 2-3 week intervals showing better outcomes than intermittent dosing 9
• Limit total number of injections and use the lowest effective dose 5

If Systemic Steroids Are Unavoidable

• Use the absolute minimum dose and shortest duration possible (ideally <5 mg prednisone equivalent for <3 months) 4, 5
• Doses >7.5 mg/day prednisone significantly increase fracture risk and should be avoided 4
• Prophylactic bisphosphonate therapy should be initiated immediately if systemic steroids are required for ≥3 months 4, 5

Mandatory Concurrent Interventions

• Calcium 1,200 mg daily and vitamin D 800 IU daily (assuming age >50) with target serum vitamin D ≥20 ng/mL 1, 4, 5
• Screen for and correct vitamin D deficiency before starting any bone-protective therapy, as 40-80% of HIV patients are deficient 1
• Exclude osteomalacia (particularly from tenofovir-induced renal phosphate wasting) before initiating bisphosphonates 1
• Weight-bearing exercise program and fall prevention strategies 4, 5
• Smoking cessation and alcohol limitation (≤1-2 drinks daily) 4, 5

Monitoring Requirements

• Perform DXA scan before steroid initiation and repeat annually if steroids are continued 1, 4
• Calculate FRAX score to determine if pharmacological osteoporosis treatment is needed (treat if 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%) 4
• If persistent hip or spine pain develops, obtain MRI immediately to evaluate for AVN, as standard radiographs miss early disease 1, 2, 3
• Image both hips if AVN is suspected, as bilateral disease is common 3

Parkinson's Disease Considerations

• Corticosteroids can cause psychiatric derangements including mood swings, personality changes, and psychotic manifestations, which may complicate Parkinson's disease management 5
• Monitor for neuropsychiatric adverse effects closely, as existing emotional changes from Parkinson's may be aggravated 5

Critical Pitfalls to Avoid

• Never use prophylactic corticosteroids or antihistamines when initiating antiretroviral therapy, as this increases rash incidence 1
• Do not assume normal radiographs exclude AVN—MRI is required for diagnosis 2, 3
• Avoid treating osteopenia with bisphosphonates until vitamin D deficiency and osteomalacia are excluded 1
• Do not continue corticosteroids beyond the minimum necessary duration, as AVN risk increases with prolonged exposure 1, 2

Alternative Management Strategies

• Prioritize non-steroidal approaches: NSAIDs, physical therapy, weight reduction, and walking aids for symptom management 2, 3
• Consider surgical options (core decompression, joint replacement) if AVN develops, as no effective medical therapy exists for established disease 1