The treatment of corticosteroid-induced osteoporosis
To reduce the risk of osteoporosis, doses of oral corticosteroids should be as low as possible and courses of treatment as short as possible. The risk of osteoporosis may be related to cumulative dose of corticosteroids; even intermittent courses can therefore increase the risk. The greatest rate of bone loss occurs during the first 6-12 months of corticosteroid use and so early steps to prevent the development of osteoporosis are important. Long-term use of high-dose inhaled corticosteroids may also contribute to corticosteroid-induced osteoporosis.
Patients taking (or who are likely to take) a corticosteroid for 3 months or longer should be assessed and where necessary given prophylactic treatment; those aged 65 years are at a greater risk. Patients taking oral corticosteroids who have sustained a low-trauma fracture should receive treatment for osteoporosis. The therapeutic options for prophylaxis and treatment of corticosteroid-induced osteoporosis are the same.
First Line Bisphosphonate
GREEN Alendronate tablets 70mg once weekly + prescribe Adcal D3 1 tab twice daily
An effervescent formulation of alendronic acid , for specific patients with swallowing difficulties, is available as an alternative to improve compliance. Consultant initiation only.
AMBER Alendronic acid effervescent tablets 70mg (Binosto®)
Second Line Bisphosphonate
GREEN Risedronate tablets 35mg once weekly + prescribe Adcal D3 1 tab twice daily tablets 5mg daily + prescribe Adcal D3 1 tab twice daily
Third Line Bisphosphonate
GREEN Disodium Etidronate 400mg + Calcium Carbonate eff 1.25g (Didronel PMO®)
| Treatment of bone loss associated with long-term systemic glucocorticoid therapy in adult patients at increased risk of fracture
|Patients with any of the following clinical features may be considered for treatment with denosumab:
| > Upper gastrointestinal abnormalities, including oesophageal stricture, achalasia, abnormalities
| which delay oesophageal emptying, dysphagia, oesophageal disease (oesophagitis, ulcers,
| erosions), gastritis, duodenitis, gastric ulcers, previous upper GI surgery.
| > Inability to sit or stand upright for at least 30 minutes.
| > Renal impairment (eGFR <35ml/min). (Denosumab’s SPC states there is no data for patients
| with eGFR < 30ml/min. Many clinicians are happy to use if eGFR > 20ml/min, provided serum
calcium is closely monitored after each injection).
| > Concerns about compliance with treatment – may include patients with cognitive impairment.
| AMBER Denosumab (Prolia®)
| SHARED CARE access the shared care agreement here
6.6.1 Calcitonin and teriparatide
Calcitonin is sometimes used in patients with hypercalcaemia of malignancy.
RED Calcitonin (Salmon)/Salcatonin injection 50 units/ml
Teriparatide (NICE TA161)
Teriparatide is recommended as an alternative treatment, after Alendronate, Risedronateand Raloxifene have been considered, for the secondary prevention of osteoporotic fragility fractures in postmenopausal women:
- who are unable to take alendronate and either risedronate or etidronate, or have a contraindication to or are intolerant of alendronate and either risedronate or etidronate (as defined in section 2), or who have an insatisfactory response (as defined in section 3) to treatment with alendronate, risedronate or etidronate and
- who are 65 years or older and have a T-score of -4.0 SD or below, or a T-score of -3.5 SD or below plus more than two fractures, or who are aged 55 - 64 years and have a T-score of -4 SD or below plus more than 2 fractures.
1. For the purposes of this guidance, independent clinical risk factors for fracture are parental history of hip fracture, alcohol intake of 4 or more units per day, and rheumatoid arthritis.
2. For the purposes of this guidance, intolerance of alendronate, risedronate or etidronate is defined as persistent upper gastrointestinal disturbance that is sufficiently severe to warrant discontinuation of treatment, and that occurs even though the instructions for administration have been followed correctly.
3. For the purposes of this guidance, an unsatisfactory response is defined as occurring when a woman has another fragility fracture despite adhering fully to treatment for 1 year and there is evidence of a decline in BMD below her pre-treatment baseline.
NB. Teriparatide for the treatment of osteoporosis in men at increased risk of fragility fractures has a BLACK traffic light.
RED Teriparatide pre-filled pen 750microgram/3mL