“If you picked up a vertebral fracture in someone who has a T score of -0.8, that patient should be treated because a vertebral fracture is one of the major risk factors for future fractures,” Dr. Grossman says. Getting reimbursement for a vertebral fracture analysis can be a problem, one she hopes will change given these new recommendations. “Since a third of all vertebral fractures are clinically apparent, you might end up treating a third more patients if you were able to do this analysis,” she notes.
Several other factors can indicate an increased fracture risk for patients taking glucocorticoids longer than three months, including low body mass index, parental history of hip fracture, smoking, consuming three or more alcoholic drinks a day, higher daily glucocorticoid dose, higher cumulative glucocorticoid dose, intravenous pulse glucocorticoid use, or declining central bone mineral density measurement that exceeds the least significant change.
Dr. Grossman says that the patient’s age and a history of falls are significant fracture risks. In addition to questioning all patients about recent falls, physicians should observe their patient’s gait and take an annual height measurement.
Prevention and Management
For patients who will be taking glucocorticoids for at least three months or who have taken them for three months or more already, the 2010 recommendations advise that pharmacologic treatment be prescribed for postmenopausal women and men aged 50 and older who have a low fracture risk if they are taking at least 7.5 mg or prednisone per day. This therapy can include alendronate, risedronate, or zoledronic acid. (See Figure 1)
Patients at medium or high fracture risk should begin therapy if they are taking any dose of glucocorticoids for three months or longer. Teriparatide is added to the treatment choices for patients who are at high risk. Estrogen replacement and testosterone therapies are no longer endorsed.
The recommendations are more complicated and less conclusive for premenopausal women because of the paucity of data from randomized controlled trials. “Very few of the studies had enough of a sample size to even comment on fracture outcomes in premenopausal patients,” Dr. Grossman says.
The recommendations for premenopausal women, which also pertain to men younger than age 50, only apply to those patients in that age group who have a history of fragility fracture. Pharmacologic treatment recommendations for this group are also different for a woman who has childbearing potential than for one who does not. (See Figure 2) Pharmacologic treatment, including alendronate, risedronate, or zoledronic acid, is recommended for women with nonchildbearing potential and for men in this age group if they are taking 5 mg or more of prednisone per day for one to three months. Drugs with shorter half-lives are recommended for women of childbearing potential. For any dose of glucocorticoids, if patients are on steroids or anticipate being on steroids for three or more months, the same medications and teriparatide are recommended.
