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
Patients starting on prednisolone where the total annual dose is expected to be 630mg or more should be referred for Dual Energy X-ray absorptiometry (DEXA). Please refer to the DEXA page for further details.
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. 25-01-24
Most patients with corticosteroid induced osteoporosis can be managed in primary care. Criteria for referrals to secondary care are:
- Severe spinal osteoporosis (T-score <-4.0 or below)
- Postmenopausal women with at least one severe or two moderate vertebral fractures and a T-score at any site of <-1.5 .
- 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. Whilst awaiting the DEXA scan, treatment should be started in patients who have sustained a previous low impact fracture and for patients with a major osteoporotic fracture risk >10%.
Once the DEXA result is available, treatment should be continued in patients with a BMD T-score at any site of <1.5. Standard treatment consists of alendronic acid 70mg once a week accompanied by cholecalciferol 800 units daily. A combined calcium and vitamin D supplement (Accrete D3, 1000/880) is indicated in patients with dietary calcium intake <700mg daily. Dietary calcium intake is usually noted on DEXA reports but can be calculated by completion of a simple food frequency questionnaire using a dietary calcium calculator.
If the patient has GI intolerance with oral alendronate tablets, Risedronate 35mg once a week or liquid buffered alendronate (Binosto, 70mg weekly) are alternatives.
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 in 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 when treatment should be continued. Treatment should be stopped after 10 years unless there has been bone loss of >4% in which case, referral to the osteoporosis service is recommended.
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)
