The updated guidelines highlight new recommendations for medications, flexibility in drug selection, and sequential therapy.
The American College of Rheumatology released a summary of its guideline updates for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis (GIOP) for the first time since 2017. Although glucocorticoids (GCs) are commonly used to treat a variety of inflammatory conditions, patients taking GCs who have risk factors for osteoporosis are at an increased risk of developing GIOP.
“One major side effect of glucocorticoid therapy is bone loss and an increase in the risk of fractures. Fractures can cause significant morbidity and be associated with an increased risk of mortality,” Mary Beth Humphrey, MD, PhD, co-principal investigator of the guideline and interim Vice President for Research and a Professor of Medicine at the University of Oklahoma Health Sciences Center, explained. “With newly approved osteoporosis medications and a review of the relevant literature, we felt it was important to update the guideline.”
Guidelines were based on an updated systemic literature review for clinical questions on treatment addressed in the 2017 guidelines, questions on new pharmacologic treatments, sequential and combination therapy, and the discontinuation of current medications.
Two new medications, abaloparatide (PTHrP) and romosozumab, were recommended in the updates, as well as other osteoporosis medications.
The guideline team granted more flexibility on drug selection, focusing on the preferences of both patient and physician preferences.
Sequential therapy, which was previously unaddressed, is now recommended for patients beginning a course of denosumab (DEN), teriparatide (PTH), PTHrP and romosozumab. Patients receiving oral/IV Bisphosphonate and selective estrogen receptor modulators (SERM) therapies do not need subsequent therapies when initial OP therapy and GC are discontinued and are considered low or moderate risk of fracture. Patients with a high risk of fracture should either continue current therapy or switch to IV Bisphosphonate, DEN, PTH/PTHrP, SERM, or romosozumab. Data was based on study designs, long term follow-up studies, and new clinical trials.
The ACR strongly recommends using oral Bisphosphonates for patients at high risk of fracture receiving long-term GCs. However, Bisphosphonates should generally not be used in patients with an estimated glomerular filtration rate (eGFR) < 35/ml/min, as it increases the risk of renal osteodystrophy. A chronic kidney disease-mineral and bone disorder (CKD-MBD) can rule out the presence of this condition and is conditionally recommended for patients with chronic kidney disease or following a renal transplant. Once excluded, there is no need to adjust doses when prescribing DEN, PTH/PTHrP, or romosozumab.
The full manuscript is expected to be published in 2023.