J Rheum Dis.  2018 Oct;25(4):263-295. 10.4078/jrd.2018.25.4.263.

Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis

• Park SY
• Gong HS
• Kim KM
• Kim D
• Kim H
• Jeon CH
• Ju JH
• Lee SS
• Park DA
• Sung YK
• Kim SW

• KMID: 2429713
• DOI: http://doi.org/10.4078/jrd.2018.25.4.263

Abstract

OBJECTIVE
To develop guidelines and recommendations to prevent and treat glucocorticoid-induced osteoporosis (GIOP) in Korea.
METHODS
The Korean Society for Bone and Mineral Research and the Korean College of Rheumatology developed this guideline based on Guidance for the Development of Clinical Practice Guidelines version 1.0 established by the National Evidence-Based Healthcare Collaborating Agency. This guideline was developed by adapting previously-published guidelines, and a systematic review and quality assessment were conducted.
RESULTS
This guideline applies to adults aged 19 years or older who are using or plan to use glucocorticoids (GCs), but does not include children and adolescents. An initial assessment of fracture risk should be performed within 6 months of initial GC use. Fracture risk should be estimated using FRAX (Fracture Risk Assessment Tool) with adjustments for GC dose, previous osteoporotic fracture history, and bone mineral density (BMD) results. All patients taking more than 2.5 mg/day prednisolone or equivalent for more than 3 months are recommended to take adequate calcium and vitamin D. Patients at moderate to high fracture risk should be treated with additional osteoporosis medication. All patients continuing GC therapy should receive an annual BMD measurement, vertebral X-ray, and fracture risk assessment using FRAX. When a treatment failure is suspected, switching to another drug should be considered.
CONCLUSION
This guideline is intended to provide guidance for clinicians in prevention and treatment of GIOP.

Keyword

Denosumab; Diphosphonates; Glucocorticoids; Osteporosis; Teriparatide

MeSH Terms

Adolescent
Adult
Bone Density
Calcium
Child
Denosumab
Diphosphonates
Evidence-Based Practice
Glucocorticoids
Humans
Korea
Miners
Osteoporosis*
Osteoporotic Fractures
Prednisolone
Rheumatology
Risk Assessment
Teriparatide
Treatment Failure
Vitamin D
Calcium
Denosumab
Diphosphonates
Glucocorticoids
Prednisolone
Teriparatide
Vitamin D

Figure

• 

  Figure 1 Flowchart of the systematic search of literature and selection process for the development of glucocorticoid-induced osteoporosis by adaptation. NGC: National Guideline Clearinghouse, G-I-N: Guidelines International Network, KoMGI: Korean Medical Guideline Information Center, GC: glucocorticoid.

• 

  Figure 2 Initial fracture risk assessment. A clinical fracture risk assessment includes obtaining a history with the details of glucocorticoid (GC) use (dose, duration, pattern of use), an evaluation for falls, fractures, frailty, and other osteoporosis (OP) risk factors (malnutrition, significant weight loss or low body weight, hypogonadism, secondary hyperparathyroidism, thyroid disease, family history of hip fracture, history of alcohol use [at ≥3 units/day] or smoking) and other clinical comorbidities, and a physical examination including measurement of weight and height (without shoes), testing of muscle strength, and assessment for other clinical findings of undiagnosed fracture (i.e., spinal tenderness, deformity, and reduced space between lower ribs and upper pelvis) as appropriate given the patient's age. The risk of major osteoporotic fracture calculated with the FRAX tool (https://www.shef.ac.uk/FRAX/tool.jsp) should be increased by 1.15, and the risk of hip fracture by 1.2, if the prednisone dose is >7.5 mg/day (e.g., if the calculated hip fracture risk is 2.0%, increase to 2.4%). It is recognized that in some cases, bone mineral density (BMD) testing may not be available. Adapted from Buckley et al. Arthritis Care Res (Hoboken) 2017;69:1095-110 [16], with permission of the American College of Rheumatology.

• 

  Figure 3 Reassessment of fracture risk. A clinical fracture risk reassessment includes obtaining a history with the details of glucocorticoid (GC) use (dose, duration, pattern of use), an evaluation for falls, fractures, frailty, and other osteoporosis (OP) risk factors (malnutrition, significant weight loss or low body weight, hypogonadism, secondary hyperparathyroidism, thyroid disease, family history of hip fracture, history of alcohol use [at ≥3 units/day] or smoking) and other clinical comorbidities, and a physical examination including measurement of weight and height (without shoes), testing of muscle strength, and assessment for other clinical findings of undiagnosed fracture (i.e., spinal tenderness, deformity, and reduced space between lower ribs and upper pelvis) as appropriate given the patient's age. Very highdose GC treatment was defined as treatment with prednisone ≥30 mg/day and a cumulative dose of >5 g in the past year. Reliability of FRAX (https://www.shef.ac.uk/FRAX/tool.jsp) after OP treatment is debated, but FRAX calculation can be repeated in adults age ≥40 years who have not received treatment. It is recognized that in some cases, bone mineral density (BMD) testing may not be available. Adapted from Buckley et al. Arthritis Care Res (Hoboken) 2017;69:1095-110 [16], with permission of the American College of Rheumatology.

• 

  Figure 4 Initial pharmacologic treatment for adults. Recommended doses of calcium and vitamin D are 1,000~1,200 mg/day and 600~800 IU/day (serum level ≥20 ng/mL), respectively. Lifestyle modifications include a balanced diet, maintaining weight in the recommended range, smoking cessation, regular weight-bearing and resistance training exercise, and limiting alcohol intake to 1~2 alcoholic beverages/day. Very high-dose glucocorticoid (GC) treatment was defined as treatment with prednisone ≥30 mg/day and a cumulative dose of >5 g in the past year. The risk of major osteoporotic fracture calculated with the FRAX tool (https://www.shef.ac.uk/FRAX/tool.jsp) should be increased by 1.15, and the risk of hip fracture by 1.2, if the prednisone dose is >7.5 mg/day (e.g., if the calculated hip fracture risk is 2.0%, increase to 2.4%). It is recognized that in some cases, bone mineral density (BMD) testing may not be available. SERM: selective estrogen receptor modulator. Adapted from Buckley et al. Arthritis Care Res (Hoboken) 2017;69:1095-110 [16], with permission of the American College of Rheumatology.

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