How should adults below 40 years be treated for Glucocorticoid Induced Osteoporosis?
Risk stratification in this young adult patient population depends on history of prior fragility fracture, Z-score, prednisone dose, and bone loss by DXA scan:
- • Low risk: no risk factors other than being on prednisone
- • Medium risk:
- • Spine or hip Z-score ≤ –3, or
- • A >10% decrease in BMD in 1 year and continuing prednisone ≥7.5 mg/day for ≥6 months, or
- • High-dose prednisone exposure (≥30 mg/day and total dose >5 g in last year) in patients aged ≥30 years
- • High risk: prior osteoporotic fragility fracture.
Bisphosphonates (alendronate, risedronate, IV zoledronic acid), denosumab, and teriparatide have been used successfully in young adult patients on GCs. Pharmacologic recommendations for patients either starting or currently on GCs with an anticipated duration of therapy of ≥3 months are as follows:
- • Low-risk patients: treat with oral bisphosphonates if >10% loss of BMD in 1 year or expected to receive >5 g of prednisone in total over the next year
- • Medium-risk patients: treat with bisphosphonates or denosumab. Consider teriparatide if pregnancy anticipated
- • High-risk patients: same as medium-risk patients or teriparatide. Use teriparatide in high-risk patients (Z-score ≤–3 and history fragility fracture).
Therapeutic guidelines for premenopausal women with childbearing potential, who have had a previous fragility fracture, recommend treatment only if they are continuing prednisone. Oral risedronate theoretically may be the safest oral bisphosphonate in this circumstance due to potential of less fetal toxicity should the patient become pregnant. Teriparatide is an alternative option. Denosumab is contraindicated in pregnancy.