The authors report no relevant financial disclosures.
Patients receiving long-term glucocorticoids should use oral bisphosphonates to reduce the risk for bone loss and fracture, according to new guidelines currently under peer review from the American College of Rheumatology.
The new recommendations would update the previous 2017 ACR guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis. The ACR anticipates publishing the new guidelines in early 2023, according to a press release. The full summary of updated guidelines is available online.
“One major side effect of glucocorticoid therapy is bone loss and an increase in the risk of fractures,” Mary Beth Humphrey, MD, PhD, co-principal investigator of the guidelines, and a professor of medicine at the University of Oklahoma Health Sciences Center, said in the release. “Fractures can cause significant morbidity and be associated with an increased risk of mortality. With newly approved osteoporosis medications and a review of the relevant literature, we felt it was important to update the guideline.”
The prospective guidelines aim to provide physicians with a template for preventing and managing glucocorticoid-induced osteoporosis through sequential therapy following the use of denusomab (Xvega, Amgen), parathyroid hormones or romosozumab (Evenity, Amgen), to minimize the risks of rapid bone loss and fracture risks. Additionally, the new guidelines contain recommendations regarding abaloparatide (Tymlos, Radius) and offer some more flexibility in drug choice for physicians and patients, according to the ACR.
To develop the updated guidelines, the authors conducted a systematic literature review regarding interventions to address, including non-pharmacologic and pharmacologic treatments, new pharmacologic treatments, discontinuation of medications and sequential and combination therapy. The authors then evaluated the resulting evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) technique.
After the review was completed and recommendations compiled, a voting panel worked to achieve a consensus of 70% or more for each prospective recommendation. The team also determined whether each piece of guidance would be considered “strong” or “conditional.”
For adults who take glucocorticoids over the long term, the authors drafted a strong recommendation for patients to receive oral bisphosphonates. According to a summary of the guidelines, patients completing a course of denosumab should transition to 1 to 2 years of a bisphosphonate, or depending on the clinical scenario, transition to teriparatide, abaloparatide or romosozumab. Meanwhile, patients completing a course of teriparatide, abaloparatide or romosozumab should transition to a bisphosphonate or denosumab. Patients completing a course of teriparatide/abaloparatide may transition to romosozumab followed by a bisphosphonate, according to the summary.
Additionally, for patients receiving glucocorticoids who are at a moderate or high risk for fracture, the panel recommended oral or intravenous bisphosphonates, teriparatide/abaloparatide or denosumab as the preferred therapies, depending on patient and physician preferences. If all risks are properly evaluated, selective estrogen receptor modulators or romosozumab may be used, the summary said.
“Some physicians may be surprised about the need for sequential therapy when completing a course of denosumab, parathyroid hormone/parathyroid hormone related protein, or romosozumab,” Linda Russell, MD, director of perioperative medicine and the osteoporosis and metabolic bone health center for the Hospital for Special Surgery, in New York, and co-principal investigator of the guideline, said in the ACR release. “If not done, patients could be at risk of rapidly developing vertebral fractures and bone loss.”