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  • Review Article
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Glucocorticoid-induced osteoporosis: who to treat with what agent?

Nature Reviews Rheumatology volume 11, pages 98–109 (2015)Cite this article

Subjects

Key Points

  • Glucocorticoid use is associated with an increase in fracture risk that can begin early in the course of therapy, linked with both daily and cumulative dose

  • Reduced bone formation and increased cortical porosity are key pathogenetic features of glucocorticoid-induced osteoporosis (GIOP)

  • The underlying disease also contributes to bone loss and increased fracture risk in glucocorticoid-treated patients

  • Early, preventive anti-osteoporosis measures, based on FRAX®-related intervention thresholds, are recommended for patients receiving chronic glucocorticoid therapy

  • Lifestyle and nutritional measures advocated for patients with GIOP are identical to those for patients with primary osteoporosis

  • Pharmacological anti-osteoporotic therapy could be stopped upon withdrawal of glucocorticoids unless the patient remains at increased risk of fracture

Abstract

Among the adverse events of glucocorticoid treatment are bone loss and fractures. Despite available, effective preventive measures, many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated for bone health and fracture risk. Populations with, or at risk of, glucocorticoid-induced osteoporosis (GIOP) to target for these measures are defined on the basis of dose and duration of glucocorticoid therapy and bone mineral density. That patients with GIOP should be treated as early as possible is generally agreed upon; however, diversity remains in intervention thresholds and management guidelines. The FRAX® algorithm provides a 10-year probability of fracture that can be adjusted according to glucocorticoid dose. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. Available anti-osteoporotic therapies such as anti-resorptives including bisphosphonates and the bone anabolic agent teriparatide are effective for the management of GIOP. Prevention with calcium and vitamin D supplementation is less effective than specific anti-osteoporotic treatment. Anti-osteoporotic treatment should be stopped at the time of glucocorticoid cessation, unless the patient remains at increased risk of fracture.

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Figure 1: Physiopathology of GIOP in inflammatory diseases.

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Acknowledgements

The authors thank K. Giroux for her secretarial assistance.

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Authors and Affiliations

  1. Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva 14, 1211, Switzerland

    René Rizzoli & Emmanuel Biver

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  1. René Rizzoli
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  2. Emmanuel Biver
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Both authors contributed equally to researching data for the article, made substantial contributions to discussion of content, writing and reviewing/editing of the manuscript before submission.

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Correspondence to René Rizzoli.

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Rizzoli, R., Biver, E. Glucocorticoid-induced osteoporosis: who to treat with what agent?. Nat Rev Rheumatol 11, 98–109 (2015). https://doi.org/10.1038/nrrheum.2014.188

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