Practice Cases
Corticosteroid-Induced Osteoporosis
Anna Golob, MD Literature reviewed October 17, 2011. Updated December 14, 2011A 63 year old woman with hypertension presents to your clinic with one week of severe pain in her shoulders and thighs. Her erythrocyte sedimentation rate is elevated and you diagnose her with polymyalgia rheumatic (PMR). You plan to start her on prednisone therapy to treat this condition.
Given that most patients with PMR require oral glucocorticoid therapy for several months to several years, you are concerned about the increased risk of osteoporosis associated with this medication. The patient denies any known history of osteoporosis or personal history of fractures. Her mother fractured her hip in a fall at age 82.
- Past Medical History:
- Hypertension
- Hypothyroidism
- Menopause age 52
- Medications:
- Levothyroxine 125 mcg daily
- Hydrochlorothiazide 25 mg daily
- Aspirin 81 mg daily
- Prednisone 40mg daily (starting during today’s visit
- Social History:
- Tobacco: Remote smoking history, quit over 20 years ago
- Alcohol use: 1-2 drinks per week
- Physical Exam:
- Weight: 140 lbs, Height 5’1"
- General: Well-nourished Caucasian woman
- Musculoskeletal : Diffuse tenderness to palpation and decreased active range of motion of the proximal hip/leg and shoulder/arm girdle
Click an answer under each question.
You recommend that she begin taking prednisone at a dose of 40 mg daily, with a plan to taper and stop eventually provided her PMR symptoms do not recur. At what daily prednisone dose will her rate of bone density loss and increased fracture risk return to baseline?
Once this patient starts taking prednisone, how soon does oral glucocorticoid-induced bone density loss occur and how much bone density can we expect her to lose per year?
- Option A Starting within the first day of use and peaking at one month; 1-2% BMD loss per year
- Option B Starting within the first three months of use and peaking at six months; 10-30% BMD loss per year
- Option C Starting within the first year of use and peaking at two years; 30-50% BMD loss per year
- Option D Starting within the two years of use and peaking at five years; >50% BMD loss per year
Given that you are starting this patient on a long (>3 month) course of oral glucorticoids, how should you evaluate her risk for bone density loss and fracture?
You appropriately order a DEXA scan to help in your determine this patient’s fracture- risk category with long-term oral glucocorticoid (1). Her femoral neck T-score is -2.0. What is her FRAX - calculated 10 year risk of major osteoporotic fracture? (2). Recall that she is 63 years of age, weight 140 pounds, height 61 inches and her mother had a hip fracture.
Our patient is in the highest risk category for cortosteroid-related fracture associated with a prolonged (>3 month) course of oral glucocorticoid. What should be done to minimize her bone density loss and fracture risk?
- Option A Advise weight bearing activities and avoidance of excessive alcohol intake
- Option B Advise supplementation with calcium 1200-1500 mg daily and Vitamin D 800-1000 IU daily
- Option C Start a bisphosphonate in addition to lifestyle modifications and calcium and vitamin D supplementation
- Option D Start combined estrogen-progesterone therapy in addition to calcium and vitamin D supplementation
This patient falls into the high risk category for glucocorticoid-induced fractures, per the 2010 ACR guidelines. You decide to start her on alendronate simultaneously with initiating glucocorticoids. How should you monitor her for changes in her bone mineral density over time?
- Option A Bone mineral density should be measured yearly until stable, then every one to three years
- Option B Bone mineral density should be measured every six months
- Option C Bone mineral density should be measured every five years
- Option D No monitoring is necessary if the patient is adherent to recommended preventative therapies