Fractures In High-risk Patients Research Articles

Update on Atypical Femoral Fractures.

➤ Atypical femoral fractures (AFFs) are stress fractures between the lesser trochanter and the metaphyseal flare that are most commonly related to prolonged (3 to 5 years) antiresorptive medication use.➤ An important finding is a visible transverse line in the lateral cortex, known as the "dreaded black line." Complete fractures are transverse and have minimal comminution.➤ Prodromal symptoms including hip, groin, thigh, and knee pain are present in more than one-half of cases and are usually misdiagnosed.➤ Nonoperative treatment for all patients with AFF includes withdrawal of bisphosphonates, assessment for secondary causes of osteoporosis, and optimization of vitamin D and calcium.➤ Incomplete fractures without a visible line can initially be treated nonoperatively with protected weight-bearing.➤ Intramedullary nailing is indicated for complete fractures and incomplete fractures with a visible fracture line. Delayed healing after fixation should be anticipated.➤ Treatment with parathyroid hormone (PTH) analogs (teriparatide and abaloparatide) after AFF prevents other fractures in high-risk patients, but the effect on healing of the fracture is unclear.

The effect of fixation type on periprosthetic fractures in high-risk patients who have osteoporosis undergoing total joint arthroplasty

IntroductionMinimizing the burden of periprosthetic fractures (PFF) following total joint arthroplasty (TJA) with regard to morbidity and mortality remains an outcome of interest. Patient and surgical risk factors, including osteoporosis and fixation type, have not truly been optimized in patients undergoing TJA as a means to reduce the risk of PFF. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA? MethodsWe queried an all-payer, national database from April 1, 2016 to December 31, 2021, to identify high-risk and low-risk patients who underwent TJA with a cementless or cemented fixation. High-risk patients met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years old who have the following: tobacco use, alcohol abuse, body mass index <18.5, prior fragility fracture, chronic systemic corticosteroids, or genetic condition affecting sex hormones or bone mineral density. Exclusion criteria were a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and a minimum follow-up of less than 2 years. ResultsThere were 384,783 patients (67.1 %) who underwent cementless TKA and 67,774 patients (11.8 %) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9 %) who underwent cemented THA and 58,667 patients (10.2 %) who underwent cementless THA and were considered high risk. The cementless cohort had a 5-year periprosthetic fracture risk following TKA of 7.8 % (95 % CI, 5.56 to 10.98) in comparison to 4.30 % in the cemented cohort (85 % CI, 3.98 to 4.65), P < 0.0001. The high-risk cementless cohort had a 5-year periprosthetic fracture risk following THA of 7.9 % (95 % confidence interval (CI), 6.87 to 9.19) in comparison to 7.78 % in the cemented cohort (85 % CI, 6.77 to 8.94), P < 0.0001. ConclusionThere is an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but no clinically meaningful difference between the two groups. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate patients for TJA based on bone quality and fracture risk can help expedite the process of improving the current state of practice.

Are Femoral Stems in Primary Total Knee Arthroplasty Cost Effective in High Fracture Risk Patients? A Risk Model and Cost Analysis.

Femoral stemmed total knee arthroplasty (FS TKA) may be used in patients deemed higher risk for periprosthetic fracture (PPF) to reduce PPF risk. However, the cost effectiveness of FS TKA has not been defined. Using a risk modeling analysis, we investigate the cost effectiveness of FS in primary TKA compared with the implant cost of revision to distal femoral replacement (DFR) following PPF. A model of risk categories was created representing patients at increasing fracture risk, ranging from 2.5 to 30%. The number needed to treat (NNT) was calculated for each risk category, which was multiplied by the increased cost of FS TKA and compared with the cost of DFR. The 50th percentile implant pricing data for primary TKA, FS TKA, and DFR were identified and used for the analysis. FS TKA resulted in an increased cost of $2,717.83, compared with the increased implant cost of DFR of $27,222.29. At 50% relative risk reduction with FS TKA, the NNT for risk categories of 2.5, 10, 20, and 30% were 80, 20, 10, and 6.67, respectively. At 20% risk, FS TKA times NNT equaled $27,178.30. A 10% absolute risk reduction in fracture risk obtained with FS TKA is needed to achieve cost neutrality with DFR. FS TKA is not cost effective for low fracture risk patients but may be cost effective for patients with fracture risk more than 20%. Further study is needed to better define the quantifiable risk reduction achieved in using FS TKA and identify high-risk PPF patients.

Use of Clinical Practice Guidelines and Quality Metrics to Assess Primary Care Management of Osteoporosis.

Background: Clinical practice guidelines and quality measures provide recommendations for physicians addressing osteoporosis management. This study explored the alignment of osteoporosis clinical practice in a primary care geriatric clinic with recommended guidelines. Methods: This retrospective chart review included 388 patients 65 or older from a primary care geriatric clinic diagnosed with osteopenia or osteoporosis, with or without a fragility fracture. Data included history of falls and use of DXA scans, FRAX® fracture risk assessment tool, osteoporosis medication, and fall risk mitigation plans. Results: For age-related primary fracture prevention, 68% of women and 87% of men had documented DXA scans, and 45% of patients diagnosed with osteoporosis and 42% determined at high risk were prescribed osteoporosis medication. For secondary fracture prevention, 72% of women aged 67 to 85 had DXA scans and 21% were prescribed osteoporosis medication. Only 10% of patients with a history of falls had documented fall risk management plans. Conclusion: Although showing higher rates of primary and secondary prevention outcomes than did research results from general primary care, gaps were identified for high fracture risk patients and fall risk management documentation. Medical record review may not provide sufficient data to capture factors influencing decision-making for fracture prevention.

Outcomes in Ankle Fracture Surgery: A Systematic Review and Meta-Analysis of Fibular Intramedullary Nail Fixation vs Open Reduction and Internal Fixation in Randomized Controlled Trials

Category: Trauma; Ankle; Ankle Arthritis; Diabetes Introduction/Purpose: What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. Methods: A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. Results: The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P=0.008). No evidence of an effect difference for bony union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. Conclusion: The quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.

Polypharmacy and medication related falls risk in orthogeriatric femoral fracture patients Polypharmacy and medication related falls risk in orthogeriatric femoral fracture patients

Aim: To reportpolypharmacy rates and identify specific medications that increase falls riskin orthogeriatric femoral fracture patients. Method: A retrospectivesub-analysis, using the electronic medical records of patients admitted with a minimaltrauma femoral fracture to a tertiary teaching hospital during a 12-monthperiod was undertaken. Specific medications associated with falls risk wereclassified under three specific groups: benzodiazepines, tricyclicantidepressants (TCAs), and non-benzodiazepine hypnotics. Results: A sample of 131patients was included in the audit. Of these, 99 patients (75.6%) were reportedto be taking five or more medications prior to their falls related admission.From this, 49 patients (37.4%) were taking ten or more medications. One in fivepatients were found to be taking specified falls risk medications prior toadmission, primarily benzodiazepines (75.8%). Conclusion: Orthogeriatricpatients admitted to hospital with a femoral fracture following a minimaltrauma fall were commonly taking five or more medications prior to admission.Over a third of patients that were reported to take ten or more pre-admissionmedications were taking specified falls risk medications. This highlights theneed for medication-reviews and de-prescribing, particularly focusing on fallsrisk medications, to reduce incidence of falls and minimal trauma fractures inhigh risk patients

Bisphosphonate Drug Holidays: Evidence From Clinical Trials and Real-World Studies.

ABSTRACTBisphosphonates (BPs) are commonly used in the treatment of osteoporosis and are effective in the prevention of fragility fracture. Long‐term use has been associated with the development of atypical femur fractures (AFFs) and osteonecrosis of the jaw (ONJ). Drug holidays seek to reduce the risk of insufficiency fractures (AFFs) while maintaining durable effects of long‐term treatment in the prevention of fragility fracture. Guidelines suggest that BP drug holidays be considered after 3 to 5 years. However individual factors impacting this decision and outcomes are unclear. This review examines key factors in the planning of a safe BP drug holiday and surrogate markers of fracture risk in patients discontinuing treatment. Fifteen randomized control trials and 19 real‐world studies were included, including nationwide prospective studies from several countries. Increases in bone turnover markers (BTMs) and reductions in bone mineral density (BMD) were generally observed during BP drug holidays. Resurgent bone turnover was problematic in high‐risk patients in whom fractures recurred as early as 12 months following a drug holiday. Risk factors for holiday‐related fractures included older age, low hip BMD, underweight, low medication adherence, and prevalent/incident fractures. Zoledronic acid conferred the most durable reduction in fractures, particularly after six annual infusions. Five years of alendronate was insufficient in preventing vertebral fractures in high‐risk patients embarking on a drug holiday. Relatively faster offset of antiresorptive effect was seen in risedronate users with more frequent fractures than alendronate during a drug holiday. Studies directly counterbalancing effects of long‐term treatment on AFF risk versus drug holiday outcomes in the same population were lacking. In the absence of persistently high fracture risk and following a specific treatment duration dependent on the BP used, drug holidays are safe and mitigate the risk of AFF. However, anti‐resorptive effects diminish over time; ongoing monitoring and careful planning of BP resumption is necessary. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Incidence of fractures and clinical profile of patients following up at a Fracture Liaison Service in the city of Curitiba

BackgroundOsteoporotic fractures are common, and their incidence are increasing worldwide. The first fracture doubles the risk of new fractures. Despite that, up to 80% of patients with a fragility fracture are evaluated or treated to reduce the risk of new fractures.AimsTo evaluate the results of the operation of the hospital Fracture Liaison Service (FLS) and to analyze the clinical characteristics of the patients attending the service in its first 2 years of operation and to estimate the fracture risk reduction ratio.MethodsThe FLS managed patients older than 50 years who were admitted with a low-energy trauma fracture between January 2017 and April 2018. This management consists in a full medical evaluation, nutritional and physical activity guidance, and specific osteoporosis treatment, if needed.ResultsWe monitored and treated 135 patients. Forty percent of them had a previous fracture and only 20.3% of them received treatment to prevent new fractures. On Kaplan–Meier analysis, the estimated incidence of new fractures over 24 months was 12.1% (95% CI 7.2–20.8%), indicating that the percentage of patients without new fractures due to bone fragility during treatment was estimated at 87.9% (95% CI 79.2–92.8%).ConclusionsThe evaluation and treatment of patients who sustained a fragility fracture to prevent a secondary fracture is effective in reducing the risk of new fractures in high-risk patients.

Osteoporosis in 10 years time: a glimpse into the future of osteoporosis.

Patients living with osteoporosis are projected to increase dramatically in the next decade. Alongside the forecasted increased societal and economic burden, we will live a crisis of fractures. However, we will have novel pharmacological treatment to face this crisis and, more importantly, new optimized treatment strategies. Fracture liaison services will be probably implemented on a large scale worldwide, helping to prevent additional fractures in high-risk patients. In the next decade, novel advances in the diagnostic tools will be largely available. Moreover, new and more precise fracture risk assessment tools will change our ability to detect patients at high risk of fractures. Finally, big data and artificial intelligence will help us to move forward into the world of precision medicine. In the present review, we will discuss the future epidemiology and costs of osteoporosis, the advances in early and accurate diagnosis of osteoporosis, with a special focus on biomarkers and imaging tools. Then we will examine new and refined fracture risk assessment tools, the role of fracture liaison services, and a future perspective on osteoporosis treatment.

Romosozumab for the treatment of osteoporosis in women: Efficacy, safety, and cardiovascular risk.

Increased understanding of the Wnt signaling pathway has led to the development of romosozumab, one of the most potent osteoanabolic agents to date for osteoporosis treatment. Romosozumab is a monoclonal antibody that inhibits sclerostin, a natural inhibitor of the Wnt signaling pathway. Romosozumab, by inhibiting sclerostin activates the Wnt signaling pathway, leading to increased bone formation and decreased bone resorption. The pivotal ARCH and FRAME studies established romosozumab’s fracture reduction efficacy. Romosozumab was superior to alendronate in fracture reduction and bone mineral density gain in the ARCH study. Romosozumab treatment should be followed sequentially with a potent antiresorptive agent. The antifracture efficacy gained from romosozumab is maintained or improved after transitioning to an antiresorptive agent. As one of the most potent osteoanabolic agents, the introduction of romosozumab has significantly increased our ability to treat osteoporosis. Studies have provided important information on using romosozumab with other osteoporosis medications to optimize osteoporosis treatment. Romosozumab used before antiresorptive medications is associated with more significant bone mineral density increases than when an antiresorptive agent is used before romosozumab. Romosozumab is recommended for osteoporosis treatment in patients at very high risk for fracture with low cardiovascular risk. Romosozumab is generally well tolerated, with 4%–5% of patients having injection site reactions. The ARCH trial showed a higher risk of cardiovascular events in patients receiving romosozumab. Romosozumab carries a black box warning that romosozumab should not be initiated in patients with myocardial infarction or stroke in the preceding year. However, the information on romosozumab and increased cardiovascular risk is conflicting. The risk of cardiovascular disease with romosozumab is unclear. While romosozumab has demonstrated significant osteoanabolic effect and antifracture efficacy and will benefit high fracture risk patients, further studies are needed to investigate the cardiovascular safety of romosozumab.

Treatment of high fracture risk patients in routine clinical practice

This paper describes the various medical therapy regimens prescribed to osteoporotic patients with high fracture risk and the result of treatment. We carried out a retrospective cohort study in selected Osteoporosis Centers. Patients were considered to have high fracture risk in case of a history of a low-energy hip fracture or two or more vertebral or other site fractures. A total of 812 subjects (768 women and 44 men) aged 36-95years were included. The observation period was 2285.1 patient-years. Demographic data, clinical findings, and BMD data obtained by DXA, as well as a history of fractures that had occurred during the follow-up, were included in the analysis. Overall, at baseline, there were 637 non-vertebral fractures including 104 hip fractures. A total of 590 patients had vertebral fractures; of these, 69% suffered multiple fractures. Being on treatment, 119 (14.7%) patients developed new vertebral and non-vertebral fractures. The incidence of new non-vertebral fractures and hip fractures was 39.4 and 13.1 per 1000 patient-years. The total number of vertebral fractures increased by 24.8% from 1353 to 1689. The best results of the treatment were achieved in patients who were started on zoledronic acid, denosumab, or teriparatide and had an adequate duration of treatment. Although these patients had significantly lower BMD values at the time of diagnosis compared with other patients, they showed a lower incidence of new vertebral and hip fractures, during the follow-up. Therapy of patients at high risk of fractures started with more potent treatment regimens (zoledronic acid, denosumab and/or teriparatide) of adequate duration was more effective in terms of prevention of new vertebral and hip fractures as compared with other treatment options. However, treatment appears to be challenging given the number of recurrent fractures in patients on treatment and the frequency of drug withdrawal or replacement.

High fracture risk patients with glucocorticoid-induced osteoporosis should get an anabolic treatment first.

Long-term glucocorticoid (GC) therapy induces glucocorticoid-induced osteoporosis (GIOP) and its associated fractures. Most specialty organizations recommend bisphosphonates as first-line therapies based only on bone mineral density efficacy data. Effective treatment of GIOP based on head-to-head trials with fracture endpoint has not yet been established. The pathophysiologic mechanisms of GIOP that lead to the detrimental effects on bone are not yet fully elucidated. Although GCs in an early and transitory period promote osteoclastic activity, in the current paper, we outline why GIOP is in fact a disease of the bone formation and then provide the rationale for the use of bone-forming agents as first-line therapy for patients with high fracture risk in GIOP.

Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection

BackgroundPostoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications. Methods41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured. ResultsNo surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20–100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL. ConclusionIntramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients. Level of evidenceIV

Sinus Tarsi Approach for Open Treatment and Internal Fixation of Displaced Intra-articular Calcaneal Fractures in High-Risk Patients: The New Gold Standard?

Category:Ankle, Diabetes, Hindfoot, TraumaIntroduction/Purpose:Intra-articular calcaneal fractures offer unique challenges. Wound problems and infection are significant complications in the surgical treatment of calcaneal fractures which in turn can be debilitating to patients and outcomes. The literature suggests varying wound complication rates but 21% up to 33% using the traditional extensile lateral approach in some studies. The extensile lateral approach has historically been accepted as the gold standard for fixation and treatment of these fractures. Recently there has been resurgent interest in alternative approaches to the fixation of intra-articular calcaneal fractures. Of interest is the potential of the sinus tarsi approach to decrease wound complications while having comparable reduction quality to the higher wound risk extensile lateral approach.Methods:A multi-center retrospective chart review study was implemented. The study objective was to review wound complication of the sinus tarsi approach compared with outcomes from the traditional extensile approach for fixation of displaced intra-articular calcaneal fractures. Specifically; examining a population of patients considered at high risk for wound issues, comparing radiographic and clinical outcomes.Results:In the high-risk group, only one primary complications resulted, including one patient with a history of an open fracture. All fractures healed with adequate maintenance of alignment. Chi- squared analysis resulted in a statistically significant difference in complication rates between sinus tarsi and the traditional extensile lateral approach at the 95% confidence level.Conclusion:In both high-risk and lower-risk cohorts of patients, a low rate of infection and wound problems was encountered. A limited approach through a sinus tarsi incision provides a viable option to treat displaced intra-articular calcaneus fracture patients with risk factors for wound issues. The patients all healed both their soft tissue wounds and fractures. Functional return was consistent with other study populations. Our study adds another cohort of patient data demonstrating the advantage of the sinus tarsi approach when compared to the extensile lateral in terms of decreased wound complications while maintaining quality of reductions and clinical outcomes.

Bariatric Surgery: Weighing In on Bone Loss.

Bariatric Surgery: Weighing In on Bone Loss.

Minimally Invasive Plate Osteosynthesis for Treatment of Ankle Fractures in High-Risk Patients

Wound healing problems are the most common complication after open reduction with internal fixation (ORIF) of unstable ankle fractures. The incidence is especially high among elderly patients with medical comorbidities and patients with compromised soft tissues. Minimally invasive plate osteosynthesis (MIPO) might provide a safer alternative to ORIF by preventing extensive soft tissue dissection and preserving the blood supply. We conducted a retrospective review of 44 consecutive patients who had undergone MIPO of unstable ankle fractures. All patients had a minimum 1-year follow-up (mean 82 weeks); 80% were aged ≥60 years, 52% had diabetes, and 45% had a compromised soft tissue envelope. Immediate postoperative radiographs were evaluated for the quality of reduction, and clinical records were analyzed for the complication rate. Good to excellent anatomic reduction was achieved in 89% of the patients. The overall complication rate was 27%, including 25% surgical wound dehiscence, 9% infection, and 11% loss of reduction. No patient experienced nerve injury. Those with a history of ankle fracture dislocation and a compromised soft tissue envelope preoperatively had a significantly greater incidence of surgical wound dehiscence and complications overall compared with those without (p = .016 and p = .035; p = .045 and p = .009, respectively). Peripheral vascular disease was a statistically significant predictor of surgical wound dehiscence (p = .010). The overall complication rate in our study was comparable to that seen in similar populations treated with conventional ORIF. In conclusion, our results suggest that MIPO in high-risk patients is a safe alternative, with predictable outcomes, comparable to those of traditional open techniques.

Putting the Brakes on Breaks: Osteoporosis Screening and Fracture Prevention.

Introduction:This prospective study sought to implement a screening tool to identify and risk stratify at-risk patients for osteoporosis and evaluate patient knowledge of osteoporosis and fragility fractures in an orthopedic trauma clinic affiliated with a level 1 trauma academic center.Methods:Of 297 eligible patients, 291 were screened and risk stratified. Patients completed an osteoporosis screening questionnaire and were risk stratified. Lifestyle advice was given to patients at low fracture risk. A dual-energy X-ray absorptiometry scan was ordered for patients at intermediate fracture risk. A referral was initiated for treatment to a bone health specialist in high fracture risk patients. Twenty patients completed a knowledge-based pretest/posttest.Results:A total of 291 patients were screened, which represented 97.7% of patients over the age of 50. Of those patients, 165 (56.7%) patients met criteria for further osteoporosis evaluation as they were considered either intermediate or high risk for future fractures. One hundred thirty-six (82.4%) patients were referred for bone mineral density evaluation. For the knowledge-based evaluation portion, patients had a 33% gain in knowledge (P = .0004). The largest knowledge deficit identified pertained to osteoporosis risk factors and lifestyle management.Discussion:The use of an osteoporosis screening questionnaire in the orthopedic trauma clinic produced clinically significant improvement in identification of at-risk patients. A lack of knowledge regarding osteoporosis and fragility fractures was found to exist among these patients.Conclusion:The implementation of an osteoporosis screening tool to identify, risk stratify, and treat patients with osteoporosis and related fragility fractures can be successfully integrated into a busy clinical practice.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged...

SAT0469 Ineffective Fracture Prevention by Bisphosphonate in Patients Undergoing High Dose Glucocorticoid Therapy with A Frax Ten Year Probability Greater than 5.8%

BackgroundHigh dose glucocorticoid (GC) therapy (PSL>0.8mg/kg/day) is often provided to patients with systemic rheumatic disease. GC induced osteoporosis (GIO) is a common complication of high dose GC therapy and bisphosphonate...

Prevention and Treatment of Bone Changes Associated with Exposure to Glucocorticoids

Rheumatologic diseases are associated with a proinflammatory state, which is thought to lead to many of the bone changes seen in treatment-naive patients. However, glucocorticoids remain a common treatment option for rheumatologic diseases and are known to have a negative impact on bone through direct effects on bone cells and indirect effects on calcium absorption. Despite the anti-inflammatory effect of glucocorticoids, fracture risk rises within the first 3months of treatment. As such, osteoporosis prevention and treatment needs to be considered in all patients started on chronic glucocorticoids (≥3months of treatment). For very low risk patients, conservative management with non-pharmacologic strategies may be appropriate. For the moderate to high fracture risk patients treated with glucocorticoids, pharmacologic treatment with 1 of the 4 approved medications should be considered. The challenge of educating physicians and patients of the risks of glucocorticoid induced osteoporosis remain.