A study of eight GP practices1 found that 86% of patients taking long-term or high- dose corticosteroids had not been given treatment to reduce bone loss. If the figures from this study are extrapolated it would appear that more than 250 000 people in the UK are taking continuous oral steroids and that about 215 000 are receiving no prophylaxis against osteoporosis.
Strong risk factors for osteoporosis include:
- Premature menopause (<45 years)
- Personal or family history of low-trauma fractures
- History of amenorrhoea
- Slender build (BMI <20 kg/m2)
The use of corticosteroids is not embarked upon lightly. Many people need them for respiratory, rheumatic or skin conditions. However, we must ensure that we make special efforts to reduce the risk of side-effects.
Four out of every ten patients taking doses equivalent to, or greater than, 7.5 mg of prednisolone per day for six months or more will develop osteoporosis. The new guidance gives key advice on how to limit bone loss while continuing treatment. There is also an accompanying information sheet for patients.
The guidelines lay out a systematic approach in a clear and easy-to-follow format. The recommendations are evidence based where possible, and the evidence is rated to give an idea of the level of support for each assertion. The use of an algorithm (see below) makes the guidance easier to use on a day-to-day basis, and is supported by further concise advice.
The guidance reinforces the need to inform the prospective steroid user of the associated risk of osteoporosis, and also advises on recommended lifestyle measures. These include:
- Stop smoking
- Avoid excess alcohol
- Take regular exercise
- Take measures to avoid falls
Further recommendations include:
- Calcium and vitamin D supplementation in those with a relatively deficient diet and in high-risk patient groups (e.g. housebound and elderly patients)
- Encourage the continuation of HRT
- Review the current dose, delivery method and type of corticosteroid being taken
The main option for active treatment is bisphosphonates, and although there is evidence for their effectiveness as a group,2 only etidronate is licensed, at the moment, for the prevention or treatment of corticosteroid-induced osteoporosis.
The guidelines also cover: how to select patients who require treatment, follow-up and referral where necessary. In addition there is a section on managing children.
Having seen the figures in the paper from Nottingham,1 it seems that we would do well to audit the patients on our lists who are on corticosteroids and reconsider their management with regard to these guidelines.
I suggest that we should be aiming for a target that is the inverse of the findings in the study, or even better, i.e. at least 86% of patients taking long-term or high-dose corticosteroids should have been given treatment to reduce bone loss, along with advice and guidance on self-help.
A copy of the guidance on the prevention and management of corticosteroid induced osteoporosis, along with an information sheet for patients, is available free of charge from: The National Osteoporosis Society, PO Box 10, Radstock, Bath, BA3 3YB.
- Walsh LJ, Wong CA, Pringle M, Tattersfield AE. Use of oral corticosteroids in the community: a cross sectional study. Br Med J. 1996; 313: 344-6.
- Watts NB. Treatment of osteoporosis with bisphosphonates. Rheum Dis Clin North Am 1994 Aug; 20(3): 717-34.