Preventing Glucocorticoid-Induced Vertebral Fractures

Long-term use of glucocorticoids is associated with an increased risk for osteoporotic fracture—most commonly vertebral fracture. Glucocorticoids, commonly referred to as “steroids,” (eg, cortisone, prednisone, dexamethasone) may be prescribed to limit a patient’s autoimmune response in treatment of certain medical conditions.

In a case study published in the December 27 issue of the New England Journal of Medicine, Lenore Buckley, MD, MPH, and Mary B. Humphrey, MD, PhD, reviewed the mechanisms behind glucocorticoid-induced vertebral fractures as well as current recommendations for prevention and treatment.

According to the authors’ study, glucocorticoids decrease osteoblast recruitment and accelerate apoptosis, leading to decreases in bone mineral density. Photo Source: 123RF.com.

Mechanisms Behind Glucocorticoid-Induced Spinal Fractures

Glucocorticoids increase the expression of receptor activator of nuclear factor-κB ligand (RANKL), leading to greater release of bone-resorbing osteoclasts.¹ In addition, glucocorticoids decrease osteoblast recruitment and accelerate apoptosis, leading to decreases in bone mineral density, the authors noted. Furthermore, glucocorticoids increase fracture risk by decreasing calcium absorption/reabsorption and sex hormone levels, altering parathyroid hormone pulsatility, and decreasing muscle mass.²

Risk Factors for Glucocorticoid-Induced Fracture

The risk for vertebral fracture increases within 3 months of initiating treatment with glucocorticoids and peaks at approximately 12 months.^3,4 For example, a patient taking 2.5 to 7.5 mg of prednisone daily has a twofold increased relative risk of vertebral fracture and a 50% higher risk of hip fracture compared with patients not taking prednisone, according to previous research.⁴ Other risk factors for glucocorticoid-induced fractures include age >55 years, female sex, and white race, the researchers noted.

Preventing Glucocorticoid-Induced Fractures

Prevention of glucocorticoid-induced fractures begins with identifying at-risk patients who should receive preventive treatment, the authors wrote. A summary of the 2017 American College of Rheumatology’s (ACR) guidelines on treatment for the prevention of glucocorticoid-induced osteoporosis is shown in Table 1. Drs. Buckley and Humphrey were coauthors of these guidelines.

Whenever possible, “the prednisone dose should be tapered as quickly as possible according to disease activity,” the authors wrote. They recommend bisphosphonate treatment for 5 years in patients on long-term prednisone treatment at a dose of ≥2.5 mg per day. For patients taking lower doses of prednisone, bisphosphonate treatment may be discontinued if reassessment shows that the patient’s fracture risk no longer meets the ACR’s criteria for bisphosphonate treatment.
Table 1. ACR Guidelines on Prevention of Glucocorticoid-Induced Osteoporosis in Adults Initiating Long-Term Glucocorticoid Treatment. Source: Buckley L, et al. Arthritis Rheumatol. 2017;69(8):1521-1537.

Managing Glucocorticoid-Induced Vertebral Fractures

“A vertebral compression fracture may seem like a minor issue that most patients will recover from uneventfully, and most often without surgery,” commented Benjamin T. Bjerke, MD, MS, Orthopaedic Spine Surgeon. “However, it is important to know that the mortality rate for a compression fracture is equivalent to that of a hip fracture. Compression fractures are often a symptom of a much larger problem than osteoporosis: malnutrition, decreased activity and weight-bearing exercises, balance issues, and increased fall risk. Although this is one of the smallest problems surgeons will take care of, it may have the greatest implication for patients’ overall health.”

“Most spine surgeons do not manage bone density, but it is important to communicate with medical providers (eg, primary care physicians or endocrinologists) who do treat this problem,” Dr. Bjerke said. “I take a complete fracture history, ask about osteoporosis-related drugs, and order a DEXA scan if one hasn’t been completed in the last 2 years. Providing education about osteoporosis and arranging follow-up with an appropriate medical provider is the most important part of the patient’s treatment.”

Disclosures
Dr. Bjerke has no relevant disclosures.