ACR Releases Update to Glucocorticoid-Induced Osteoporosis Guideline

“The bisphosphonates stay in your system for a long time,” Dr. Russell explains, “so when you choose to stop those medications, fracture protection continues for up to five years. But denosumab has a different mechanism of action, and it’s in your system for approximately six months. If you don’t follow up with another medication that slows bone loss, like [alendronate] or [risedronate], there can be rapid bone loss.”

According to Dr. Humphrey, we’ve been learning about this risk for the last several years, first for denosumab, but also for other agents like parathyroid hormone-based compounds and romosozumab. The risks of suddenly discontinuing these agents became very clear during the COVID-19 crisis. “If patients didn’t reschedule their denosumab and missed a dose, in that next six months they were starting to have multiple vertebral fractures,” she says.

In the current guideline, it’s strongly recommended that patients who have stopped taking glucocorticoids and are now at low risk for fracture discontinue their osteoporosis therapy. Patients discontinuing bisphosphonates or raloxifene do not need to take an additional osteoporotic prevention therapy. However, to prevent sudden bone loss and vertebral fractures, sequential therapy is strongly recommended for patients stopping parathyroid hormone-based treatments, denosumab or romosozumab.

This follow-up therapy could consist of an oral or IV bisphosphonate. At this time, we don’t know the precise timing to start anti-resorptive therapy or how long this transitional bisphosphonate therapy needs to continue, although we know that a year of therapy gives at least partial protection.⁷

Although serious complications of bisphosphonates, such as osteonecrosis of the jaw and atypical femur fractures, are quite rare, Dr. Humphrey points out they have received a lot of press attention. Some patients may be predisposed against bisphosphonates, even though some other treatment options (i.e., denosumab and romosozumab) share these rare risks. Patients need to know at the outset that even if they opt for another initial choice of therapy, they will likely eventually need to take a year of bisphosphonates to stabilize the newly formed bone and prevent vertebral fractures.

Importance of Screening

Before appropriate patients receive any treatment, they must be properly identified, which is why screening is so key. Unfortunately, the number of patients with osteoporotic fractures has increased in recent years, after a decade or so of decline, and many patients with glucocorticoid-induced osteoporosis are neither screened nor treated.

Dr. Humphrey points out that with the decrease in Medicare reimbursement rates for bone density scans, the number being performed has dropped significantly. She speculates that these increasing rates may have also been partially due to the discovery that some patients could safely take drug holidays from bisphosphonates; however, some patients on such holidays may not have re-initiated needed treatment after five years.