Bone Health Screening and Treatment in Allogeneic Hematopoietic Stem Cell Transplant (HCT) Patients

Abstract

Bone density loss is a well-recognized and common complication in allogeneic HCT recipients. Guidelines recommend screening with dual photon densitometry at 1 year post-HCT, and counseling of patients on preventative strategies along with consideration of treatment for patients at high risk for bone loss. However, osteoporosis and fragility fractures remains a major cause of morbidity, and significantly impacts the quality of life of allogeneic HCT survivors. Given the high morbidity of bone density loss in our patients, we sought to create specific guidelines, taking a more proactive approach to bone health within our program. In collaboration with the Cleveland Clinic Rheumatology department, pharmacists, and the Blood and Marrow Transplant Survivorship Program, we created specific guidelines for screening, prevention and treatment of bone loss post HCT. Given the high prevalence of older adults, pre-disposing co-morbidities and steroid use, we have initiated pre-transplant screening including Vitamin D levels and dual-energy X-ray absorptiometry (DEXA) scans on all patients during their evaluation. Patients with a history of prolonged systemic steroid use defined as ≥ 7.5 mg daily for ≥3 months are treated pre-HCT regardless of their DEXA or applied fracture risk assessment tool (FRAX) score. The DEXA and applied FRAX scores are used to determine prevention and treatment strategies for all other patients. We recommend repeat DEXA 1-year post-HCT, and recommend treatment in patients who have graft-versus-host disease requiring systemic corticosteroids (>7.5 mg prednisone equivalent for >3 months), have osteopenia or osteoporosis with a DEXA T-score of ≤ -1.0 or FRAX score (hip >3%, MOP >20%). Treatment recommendations consists of bisphosphonate therapy, yearly dosing of zolendronic acid for at least 3 years, and continuation of therapy for high risk patients (older women, vertebral fractures, low hip T-score or high FRAX score, previous major fracture, or who fracture on therapy, and continuous use of steroids). Oral bisphosphonates are considered for patients with good compliance and oral absorption. Denosumab is considered for patients with poor renal function. We provide an example of a systematic multidisciplinary approach to assess, prevent and manage bone loss in allogeneic HCT recipients. Study of patient tolerance and prevention of bone density loss in this high risk patient population with this algorithm compared to past practices is ongoing.