The American College of Rheumatology has published updated guidelines for glucocorticoid-induced osteoporosis (GIOP). Since 2017, when the last guideline was issued, new medications for treating osteoporosis have become available, prompting ACR to revisit its recommendations.
GIOP Is Common, Yet Challenging
Glucocorticoid-induced osteoporosis is a common complication of corticosteroid treatment, with fractures occurring in as many as 30% to 50% of people on chronic glucocorticoid (GC) therapy.¹ Glucocorticoids play an important role in treating a variety of diseases, not all rheumatic. For instance, while they are commonly used to treat autoimmune and inflammatory diseases, such as rheumatoid arthritis, gout, lupus, vasculitis, psoriasis, and reactive arthritis, they are also used in the management of lung diseases such as chronic obstructive pulmonary disease, asthma, and sarcoidosis.
Treating GIOP can be challenging, in particular, because it is difficult to catch early. “There is no effective method of quickly picking up the decrease in bone density,” said Shailendra Singh, MD, a rheumatologist at Unity Health in Searcy, Arkansas, and president of the Arkansas Rheumatology Association. “DEXA scan, which is usually used to measure changes in bone density, can take up to 1 year to pick up the changes, while the people taking glucocorticoids can develop osteoporosis and fractures as early as 90 days into long-term use of glucocorticoids.”
New ACR Recommendations for Abaloparatide, Romosozumab, Denosumab, and Teriparatide
ACR’s updated draft guideline, released in Fall 2023, includes recommendations on two drugs that have been approved for GIOP since the 2017 original guideline – abaloparatide and romosozumab. The update notes that when using these medications, along with conventional medications denosumab and teriparatide, patients will need additional therapy after these drugs are discontinued. After completing a course of denosumab, the guideline recommends transitioning to 1 to 2 years of a bisphosphonate or one year of romosozumab. If PTH, PTHrP, or romosozumab are chosen, the transition should be to a bisphosphonate or denosumab.
The guideline notes that stopping denosumab without transitioning to another therapy can result in vertebral fractures and bone loss. Bisphosphonate therapy is recommended six to seven months after the last dose of denosumab. While the precise timing, dose, and duration of bisphosphonate therapy following denosumab cessation is being studied, the draft guideline suggests that treatment for a least 1 year seems prudent.
“Some physicians may be surprised about the need for sequential therapy when completing a course of denosumab, parathyroid hormone/parathyroid hormone related protein, or romosozumab,” explained Linda Russell, MD, director of the Osteoporosis and Metabolic Bone Health Center for the Hospital for Special Surgery in New York, NY, and co-principal investigator of the guideline. However, she adds, “If not done, patients could be at risk of rapidly developing vertebral fractures and bone loss.”
Shared Decision-Making Recommended
The updated ACR guideline also gives prescribers more flexibility on drug selection and considers both patient and physician preferences. “The previous guideline rank-ordered medication for the treatment of glucocorticoid-induced osteoporosis. We felt it was important that this guideline reflect patient/physician decision-making,” stated Mary Beth Humphrey, MD, PhD, co-principal investigator of the guideline and interim vice president for research and professor of medicine at the University of Oklahoma Health Sciences Center, in an ACR news release.
This flexibility is helpful, particularly in adjusting the treatment depending on a patient’s comorbidities, added Dr. Singh. A patient who has severe gastritis or a history of gastrointestinal ulcers, for instance, is less likely to tolerate oral bisphosphonates while patients with moderate to severe kidney disease are more likely to develop side effects from oral or IV bisphosphonates. Still yet, individuals with bone disorders, such as bone cancer, should avoid using anabolic agents like teriparatide, abaloparatide, or romosozumab, she noted, adding, “What drug is best for a person should be decided by the physician after having detailed discussions with the patient and keeping in mind patient preferences.”
