Prevention of Steroid-Induced Osteoporosis (BSH 2019)
Note: These notes come from the BSH good practice paper linked to above. This was written specifically for steroid use in ITP. I would have thought it should make us think about osteoporosis in many of our other patients (e.g. A 70kg patient would receive >2g prednisolone after 6x R-CHOP)
Most gen med guidelines recognize a daily oral dose of >5-7.5mg prednisolone for more than three months as conferring an increased risk of osteoporosis.
Adults >40 receiving high dose intermittent steroids (at least one daily dose of >15mg for a short duration) are at risk when the cumulative dose exceeds 1g. (Source: UK GP Database)
A cumulative dose >5g associated with a relative risk increase of 14.4 for fragility fracture.
Consider treatment without additional assessment if:
Men >50 or women post-menopausal who have had a previous fragility fracture
Assess risk with the FRAX score at treatment onset if:
Age 40-69 without previous fragility fracture
Then, if scored as intermediate risk and steroid course expected to be >12 weeks in length, perform DXA scan and add femoral neck bone mineral density to the FRAX calculator.
Risk assessment not routinely required for:
Adults with a low risk FRAX score (before or after DXA)
Adults <40 and children
Interventions for all adults starting steroids:
Life style advice to optimize bone health
Check calcium and vitamin D levels
Adequate daily vitamin D (800 iu) and calcium (700-1200mg) intake (diet or supplements)
Additional interventions for adults considered high-risk (see above):
Consider oral alendronate or risedronate
If contraindicated or poorly tolerated —> zolendronic acid, denosumab or teriparatide