History
- Patient requiring oral prednisolone >7.5mg/day for >3 months.
- Cumulative annual prednisolone dose of >630mg (oral or parenteral)
Examination
- Kyphosis in patients with vertebral fractures
- Signs of underlying disease
Investigations
Dual x-ray absorptiometry
It is not necessary to refer patients aged 60 years and above who are starting prednisolone for Dual Energy X-ray absorptiometry (DEXA), since there is a high likelihood they will have osteopenia and qualify for treatment. Instead, prophylactic treatment can be commenced with an oral bisphosphonate and calcium and vitamin D supplements (see primary care management tab). Indications for DEXA in this patient group are:
- Patients under the age of 60 years
- Patients with one severe or two or more moderate vertebral fractures on X-ray (indicated if there is back pain and height loss)
- Patients who are able to come off long term prednisolone, to determine if treatment is still indicated
- Patients who have completed 5 years treatment with an oral bisphosphonate
X-rays
Thoracic and lumbar spine x-rays are indicated in patients with back pain, kyphosis or height loss to confirm of exclude the presence of vertebral fractures.
X-rays of other sites aren’t a reliable means of diagnosing osteoporosis but if an x-ray is performed for another reason and it is reported as showing osteopenia this can indicate underlying osteoporosis.
Biochemistry and haematology
The following tests are useful to exclude secondary causes of osteoporosis. They should be considered in patients with a confirmed diagnosis of osteoporosis.
- FBC and ESR
- Urea and Electrolytes
- Liver function tests
- Calcium and Albumin,
Serum 25(OH) D - Thyroid function tests
- TTG
- Serum protein electrophoresis
- Spot urine for Bence-Jones protein
- Testosterone and gonadotrophins in men
M.A & S.R/H.B. 15-10-24
Most patients with corticosteroid induced osteoporosis can be managed in primary care. Criteria for referrals to secondary care are:
- Postmenopausal women with at least one severe or two moderate vertebral fractures.
- Intolerant of both alendronic acid and risedronate
- Bone loss of >4% at any site on repeat DEXA despite adhering to oral bisphosphonate treatment
Counselling patients about treatment
Treatment should only be commenced following a discussion of the options with the patient, including the possibility of not having treatment given the fact that none of the treatments available can completely prevent fractures. You may wish to consider using the ORB calculator to work out the benefits of treatment for your patient with different drugs as part of this discussion. The ORB calculator is also available free as an iPhone app on Apple store and on Google Play for Androids. Note that if you are using FRAX (which only permits calculation of 10-year fracture risk), the risk of any osteoporotic fracture over 5 years is about 50% of the 10-year value.
Most patients with corticosteroid induced osteoporosis can be managed in primary care. Standard treatment consists of alendronic acid 70mg once a week accompanied by cholecalciferol 800 units daily. Alternatives include Risedronate 35mg once a week or liquid buffered alendronate (Binosto, 70mg weekly). A combined calcium and vitamin D supplement (Accrete D3, 1000/880) is indicated in patients with dietary calcium intake <700mg daily. Dietary calcium intake can be calculated by completion of a simple food frequency questionnaire using a a dietary calcium calculator.
Treatment should be continued so long as the patient remains on steroid therapy with a repeat DEXA after 5 years to review the need for ongoing therapy. If the patient remains on steroids at 5 years and BMD values are stable or have increased, therapy should be continued up to a maximum of 10 years.
Please consult the Endocrinology Refhelp guidance on managing patients on long term corticosteroids for further information on steroid dose reduction and screening tests to be performed prior to starting steroids and prior to stopping steroids (see further information)
If steroid is stopped before a planned 5-year review, repeat DEXA should be requested to determine the need for ongoing bone protective therapy. If the BMD T-score is in the osteoporotic range, therapy should be continued. If it is in the osteopenic range, treatment can be stopped, unless the patient has vertebral fractures, in which case treatment should be continued for up to 10 years. Treatment should be stopped after 10 years and a DEXA requested through the open access service.
Royal Osteoporosis Society (www.theros.org)
Management of osteoporosis and prevention of fragility fractures (SIGN 142)
Dietary calcium calculator. Calcium Calculator
Osteoporosis risk benefit calculator: ORB calculator
Endocrinology RefHelp guidance on management of patients on long term steroid therapy:
Management of long term high dose steroid therapy – RefHelp (nhslothian.scot)
