Osteoporosis

ACR Updates Osteoporosis Clinical Guidelines

The American College of Rheumatology (ACR) recently updated its clinical guideline for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP). The ACR last updated its GIOP guideline in 2010.

To craft the updates, the ACR writing committee used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, along with a group consensus process to decide the final recommendations and their grade strength. The updates include recommendations for adults and children ages 4 to 17 years.
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Strong recommendations for all age groups include:

  • Optimize calcium and vitamin D intake and implement lifestyle modifications, like exercising, quitting smoking, and limiting alcohol intake.
  • Men and women not of childbearing potential who face moderate to high risk of fracture should be prescribed (in order of preference) oral bisphosphonates, IV bisphosphonates, teriparatide, and denosumab. Raloxifene can be prescribed to postmenopausal women if the above medications are not suitable.

Conditional recommendations for special populations include:

  • Oral bisphosphonates should be prescribed to moderate to high–risk adult women who are of childbearing potential but are not planning to become pregnant. Teriparatide may be prescribed if bisphosphonates are not successful.
  • Solid organ transplant patients who are continuing glucocorticoid treatment and have a glomerular filtration rate higher than 30 should be treated as per recommendations for their age group. Renal transplant patients should be evaluated for metabolic bone disease and should avoid denosumab.
  • Children ages 4 to 17 years should optimize calcium and vitamin D intake and take oral bisphosphonates if they have sustained an osteoporotic fracture and are continuing glucocorticoids at 0.1 mg/kg or higher for 3 months or longer. IV bisphosphonates can be prescribed if oral treatments are not suitable.
  • Patients receiving very high doses of glucocorticoids (30 mg or higher of prednisone and a cumulative dose of more than 5 g per year) should take oral bisphosphonates.

Special considerations during osteoporosis treatment include:

  • Teriparatide or denosumab should be prescribed to those who fail treatment or sustain a fracture after 18 months of oral bisphosphonate or have a bone mineral density loss of more than 10% per year. Patients who fail due to poor adherence or poor absorption should take IV bisphosphonates.
  • Patients who have completed oral bisphosphonate treatment but still face a high risk of fracture should continue an active treatment.
  • Patients who have discontinued glucocorticoid treatment should stop osteoporosis treatment if they become low-risk for fracture, or should complete the treatment if they face moderate to high risk.

“The guideline provides direction for clinicians and patients in making treatment decisions about management decisions in patients with or at risk for GIOP,” said principal investigator Lenore Buckley, MD, MPH. “Clinicians and patients should employ a shared decision-making process that accounts for patients’ values, preferences and comorbidities.”

—Christina Vogt

Reference:

ACR releases guideline on prevention & treatment of glucocorticoid-induced osteoporosis [press release]. Atlanta, GA. American College of Rheumatology; June 7, 2017. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/812/ACR-Releases-Guideline-on-Prevention-Treatment-of-Glucocorticoid-Induced-Osteoporosis. Accessed June 8, 2017.