What is the best post-surgical management for a patient with psoriatic arthritis (PsA) on prednisolone (corticosteroid) who recently suffered a hip fracture?

Post-Hip Fracture Management in Psoriatic Arthritis Patient on Prednisolone

Start vitamin D, calcium, AND bisphosphonate therapy while continuing prednisolone at the current dose—this patient requires comprehensive glucocorticoid-induced osteoporosis (GIOP) prevention given the recent fracture and ongoing steroid use. 1

Rationale for Combined Therapy

This patient has sustained a hip fracture while on glucocorticoid therapy, which automatically places them in the high-risk category for future fractures regardless of age or BMD testing. 1 The 2017 American College of Rheumatology GIOP guidelines provide clear direction:

• Any history of osteoporotic fracture qualifies as high-risk and mandates pharmacologic treatment beyond calcium and vitamin D alone 1
• The fracture occurred while on prednisolone, confirming this is glucocorticoid-induced bone disease 1

Specific Treatment Components

Bisphosphonate Therapy

• Oral bisphosphonates are the first-line pharmacologic treatment for adults ≥40 years at high fracture risk (strong recommendation) 1
• For adults <40 years with history of osteoporotic fracture, oral bisphosphonates remain the preferred initial treatment 1
• IV bisphosphonates should be used if oral formulations are not appropriate due to post-surgical considerations, adherence concerns, or gastrointestinal issues 1
• Zoledronic acid 5 mg IV annually has demonstrated a 35% reduction in new clinical fractures and 28% reduction in mortality when given within 90 days after hip fracture repair 2

Calcium and Vitamin D

• Calcium 1,000-1,200 mg/day and vitamin D 600-800 IU/day (target serum level ≥20 ng/ml) are conditionally recommended for all patients receiving glucocorticoid treatment 1
• These are foundational but insufficient as monotherapy in high-risk patients 1

Prednisolone Management

• Continue the current daily dose of prednisolone through the perioperative period rather than discontinuing or using stress-dose steroids 1
• The ACR guidelines specifically recommend continuing glucocorticoids for patients with rheumatic diseases undergoing orthopedic surgery 1
• Abrupt discontinuation risks adrenal insufficiency and disease flare 3
• **Optimize the dose to <20 mg/day as soon as the psoriatic arthritis allows**, as doses >15-20 mg/day significantly increase infection and fracture risk 1

Critical Timing Considerations

Immediate Post-Surgical Period

• Bisphosphonate therapy can be initiated once wound healing is adequate, typically around 14 days postoperatively when sutures/staples are removed and there is no significant swelling, erythema, or drainage 1, 3
• If using IV zoledronic acid, administration within 90 days of hip fracture repair provides maximal benefit for fracture reduction and mortality 2

Long-Term Monitoring

• Reassess fracture risk every 1-3 years with BMD testing 1
• Earlier reassessment is warranted if prednisolone dose remains ≥30 mg/day or cumulative dose ≥0.5 gm in the previous year 1

Why Option C (Vitamin D and Calcium Only) Is Inadequate

A history of osteoporotic fracture mandates pharmacologic treatment beyond calcium and vitamin D. 1 The ACR guidelines explicitly state that patients with prior osteoporotic fractures should receive oral bisphosphonates as first-line therapy, with calcium and vitamin D as adjunctive treatment only. 1 Relying on calcium and vitamin D alone in this high-risk patient would constitute undertreatment and fail to address the established GIOP.

Why Stopping Prednisolone (Option B) Is Inappropriate

Abruptly discontinuing glucocorticoids in a patient with active psoriatic arthritis risks both disease flare and adrenal crisis. 1, 3 The perioperative ACR guidelines specifically recommend continuing the current glucocorticoid dose through surgery rather than stopping. 1 While long-term glucocorticoid minimization is appropriate, this should be done gradually as disease control allows, not precipitously after hip fracture surgery. 1

Common Pitfalls to Avoid

• Do not delay bisphosphonate initiation indefinitely waiting for "perfect" wound healing—the 90-day window post-fracture is critical for maximal benefit 2
• Do not use calcium and vitamin D as monotherapy in patients with established osteoporotic fractures on glucocorticoids 1
• Do not abruptly stop prednisolone without a gradual taper plan coordinated with rheumatology 1
• Do not administer supraphysiologic "stress-dose" steroids perioperatively—continue the current daily dose 1