How much prednisolone is considered too much for bone?
- As low as 2.5 mg of prednisolone !
- Generally, 5-7.5 mg/day of prednisolone (or equivalent) for >3 months
- See this link: http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9
- Calculator that calculates your patient’s 10 year absolute risk of osteoporotic and hip fracture.
Problem with this is:
- Glucocorticoid therapy is a categorical variable—a yes-or-no question—and yes is defined as having ever used a
glucocorticoid in a dose greater than 5 mg for
more than 3 months.
- A patient taking 5 mg of prednisolone has the same risk of a patient taking 50 mg of prednisolone.
- Therefore, in the ACR guideline, they create a risk strata for glucocorticoid induced osteoporotic fracture.
ACR risk strata for glucocorticoid induced osteoporotic fracture
For pre-menopausal women with non-childbearing potential
- >5 mg/day for >1 month: alendronate/risedronate
- >7.5 mg/day for >1 month: above or zoledronic acid
- any dose >3 months: teriparatide
For pre-menopausal women with childbearing potential
- Treatment is recommended only when prednisolone >7.5 mg/day for >3 months.
Comparing to NICE guideline:
- FRAX score is used as the risk assessment calculator.
– In contrast to ACR, they didn’t differentiate treatment based on the doses and duration of treatment.
– Adjustment on FRAX score can be done on the dosage of corticosteroids (Kanis et al,2010)
- High risk: treatment
– Alendronate & risedronate
– Consider specialist referral for people who cannot take or tolerate alendronate or risedronate.
– No mention of zoledronic acid
- Intermediate risk: DEXA scan and recalculate the FRAX score
- Low risk: lifestyle advice
** The adjustment based on glucocorticoid dosage:
- < 2.5 mg daily of prednisolone or equivalent): probability decreases by 20%
- 2.5-7.5 mg daily, the unadjusted FRAX value can be used.
- > 7.5 mg daily, probability increases by 15%.
Remember the rule of ~20%
– <2.5 mg/day: risk decreases by 20%
– 2.5-7.5 mg/day: unadjusted FRAX score
– >7.5 mg/day: risk increases by 20%
3 things to remember
- Glucorticoid >5 mg/day for >3 months = high risk for glucocorticoid induced osteoporosis.
- Use FRAX score. Adjust the score based on glucocorticoid dosage by Kanis et al or use ACR guideline.
- Treat if high risk; BMD assessment and recalculate if intermediate; lifestyle advice if low risk.
CHAD L. DEAL, MD. Recent recommendations on steroid-induced osteoporosis: More targeted, but more complicated. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 2 FEBRUARY 2013
Kanis et al. Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int. 2011 Mar;22(3):809-16