New guidelines emphasise that high-risk patients taking steroids should also have bone protective therapy, says Dr Gillian Hosie
New evidence-based guidelines from the Bone and Tooth Society of Great Britain, the National Osteoporosis Society and the Royal College of Physicians will raise awareness of the risks of steroid therapy in relation to osteoporosis. They also provide the tools to manage patients considered at risk.
Corticosteroid therapy is used in the management of many serious conditions, such as chronic active hepatitis, systemic lupus erythematosus and temporal arteritis. It can control symptoms in inflammatory and allergic conditions and may be life-saving on occasion.
Most clinicians will have prescribed steroid therapy at some time, and if asked about its potential side-effects could probably list several, including osteoporosis. Despite this knowledge, there is still a mismatch between theory and practice, and many patients on steroid therapy are not offered preventive advice or treatment. Several factors may account for this omission.
Patients, in a wide range of disease areas, have often been started on steroid therapy by hospital specialists. Therapy is then continued in primary care without the increased risk of osteoporosis being recognised, either by those who initiated therapy or those continuing to prescribe it.
Other patients may be started on a short-term course of steroids and, as the therapy is not intended to last long, the prescriber may decide that there is no need to start preventive measures. This short course may then extend into long-term therapy and the opportunity for prevention is lost.
Another common situation is that of patients, such as those with asthma, who require short courses of high-dose steroid therapy on an intermittent basis. These courses may be given during hospital admissions or by out of hours services as well as by the patient’s own doctors. The fact that the total dose of steroid could be putting the patient at risk of osteoporosis may be overlooked because no particular individual is taking responsibility for this aspect of the patient’s care.
The guidelines give a clear message to all doctors initiating steroid therapy in patients at high risk – those aged over 65 years and those who have had a previous fracture – to start preventive treatment at the same time. This is an important message and one that needs to be emphasised.
A DEXA scan is not essential before commencing preventive therapy in high-risk patients, but in younger patients on long-term steroid therapy a DEXA scan is appropriate to assess bone mineral density and assist in making treatment decisions. There are still parts of the country where DEXA scans are not readily available, and long-term health planning should address this deficiency as a priority.
A key recommendation of the guidelines is that all patients taking steroids, whether or not on bone-protective therapy, should be advised about adequate dietary calcium, taking exercise, and avoiding smoking and overindulging in alcohol. We often underestimate the contribution that lifestyle factors can make to the development of osteoporosis and fail to counsel our patients accordingly.
The guidelines include a short summary and a management algorithm which should be followed by all clinicians who prescribe steroid therapy. A laminated card containing information for patients can be easily photocopied and provides excellent back up during a consultation as it includes lifestyle advice as well as information on the various treatment options.
These new guidelines are an excellent resource for all doctors and nurses who encounter patients on steroid therapy, and I would strongly recommend them.
Copies of Glucocorticoid-induced osteoporosis: Guidelines for prevention and treatment are available from the RCP publications department, price £15; tel: 020 7935 1174 ext 254, or at: www.rcplondon.ac.uk.