Controversies related to determination of the glucocorticoid-induced osteoporosis intervention threshold: who are the patients?

Abstract

Glucocorticoid-induced osteoporosis is the most common cause of secondary osteoporosis. The research demonstrates that oral administration of glucocorticoids often result in rapid bone loss and an increased risk of fractures during several months. The urgency of glucocorticoid-induced osteoporosis as a public health problem is caused by the frequent use of glucocorticoids by patients with various chronic diseases resulting in high level of osteoporosis. The glucocorticoid-induced osteoporosis develops due to the inhibition of bone formation, accompanied by an early but short-term bone resorption increase. An increase in the RANKL/OPG ratio, sclerostin expression growth, activation of PPARgR2, as well as hypogonadism, impaired absorption of calcium in the intestine, and a decrease of the insulin-like growth factor 1 production are among many mechanisms underlying the bone metabolism disorders caused by the long-term use of glucocorticoids. Despite available and effective preventive measures, the bone condition and risk of fractures for many patients who start or conti­nue glucocorticoid therapy are not adequately assessed. The thre­shold values of daily doses of glucocorticoids (≥ 2.5 mg/day) and the duration of their administration (≥ 3 months) at which patients’ risk of fractures and the necessity of treatment with antiosteoporotic drugs should be assessed were identified. National guidelines for the management of glucocorticoid-induced osteoporosis offer different approaches to determination of the interventions thre­shold based on the use of various criteria. The 10-year probability of fractures based on the clinical risk factors, with or without bone mine­ral density assessment, is calculated and adjusted for regional fracture rate and mortality with the Fracture Risk Assessment Tool (FRAX). Despite limitations, this algorithm is the most effective in defining the interventions thresholds. The 2017 American College of Rheumatology guidelines indicate that the initial absolute risk of fractures should be assessed using the FRAX and taking into account the doses of glucocorticoids and bone mineral density test results no later than 6 months from the start of glucocorticoids therapy.

Keywords

• glucocorticoid-induced osteoporosis
• glucocorticoids
• daily dose
• pathogenesis
• intervention thre­shold
• fracture risk
• frax
• treatment
• review