ARTICLE IN PRESS

Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, vol. ■, no. ■, 1–5, 2018
Published by Elsevier Inc. on behalf of The International Society for Clinical Densitometry.
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https://doi.org/10.1016/j.jocd.2018.03.004

Review Article

Glucocorticoid-Induced Osteoporosis: Management Challenges

in Older Patients
Robert A. Adler*,1,2
1
Endocrinology and Metabolism (111P), McGuire Veterans Affairs Medical Center, Richmond, VA, USA; and 2Endocrine
Division, Virginia Commonwealth University School of Medicine, Richmond, VA, USA

Abstract
Glucocorticoid-induced osteoporosis remains the most common type of secondary osteoporosis, mostly
due to use of oral glucocorticoids rather than due to endogenous overproduction of cortisol. Partly because
glucocorticoids are prescribed by a wide variety of clinicians for many different inflammatory disorders, only
a minority of older individuals have adequate and timely assessment of their enhanced fracture risk, and fewer
are offered treatment. Assessment should include bone density, the FRAX calculation, and, in many cases,
images of the spine. Glucocorticoids decrease osteoblast function and increase apoptosis of osteoblasts and
osteocytes, leading to increased fracture risk soon after starting glucocorticoids. Guidelines provide evidence-
based recommendations for evaluation and treatment, but there are differences in extant guidelines, and methods
to improve adherence to the guidelines have mostly failed. A strong case can be made to use anabolic drugs
first in high-risk patients based on pathophysiology and head-to-head clinical trials.
Key Words: Bisphosphonates; fracture; glucocorticoids; osteoporosis; teriparatide.

Introduction thought. The increased fracture risk of postmenopausal os-

Glucocorticoid-induced osteoporosis (GIOP) is the most
common type of secondary osteoporosis because oral glu-
cocorticoids, such as prednisone and prednisolone, are com-
monly prescribed in adults with inflammatory disorders such
as rheumatoid arthritis and chronic obstructive pulmo-
nary disease. Notably, such disorders themselves may put
patients at risk of fracture, in addition to the effect of glu-
cocorticoid therapy. Prednisone, prednisolone, and other
systemic glucocorticoids are prescribed by many differ-
ent clinicians for a wide variety of disorders. Hence, methods
to improve management of GIOP require recognition in
many different clinical settings that this is a disorder that
requires attention. In addition, new evidence suggests that
the increased fracture risk of GIOP may occur even sooner
after starting glucocorticoid therapy than was previously
Received 02/15/18; Accepted 03/7/18.
*Address correspondence to: Robert A. Adler, MD, Endocri-
nology and Metabolism (111P), McGuire Veterans Affairs Medical
Center, 1201 Broad Rock Boulevard, Richmond,VA 23249. E-mail:
Robert.adler@va.gov
teoporosis occurs over years to decades. In men, fracture
risk accelerates after about age 80. However, fracture risk
is demonstrably increased within months of starting sys-
temic glucocorticoid therapy. One reason for this is the dif-
ference in the pathophysiology of GIOP compared with that
of postmenopausal osteoporosis. In the latter, with the loss
of estrogen at menopause, bone resorption increases, and
although bone formation may increase, it is inadequate to
match the resorption. Thus, over time, fracture risk gradu-
ally increases. In GIOP, although there may be an early in-
crease in bone resorption, the most important abnormalities
are decreased osteoblast function and increased apopto-
sis of osteoblasts and osteocytes (1). There are also sec-
ondary effects of glucocorticoids, such as hypogonadism and
increases in urinary calcium excretion. These effects lead
to a marked decrease in bone mass and quality and a much
quicker increase in fracture risk. The highly cited study (2)
from the United Kingdom General Practice Research Da-
tabase demonstrated that a dose of about 5 mg of predni-
sone equivalent led to a measureable increase in fracture
risk after only 3 mo of glucocorticoid treatment. More re-
cently (3), a report suggested that even 1 mo of systemic

1
 ARTICLE IN PRESS
2 Adler

glucocorticoid was associated with increased fracture risk.
If this is confirmed by other studies, it strengthens the
need for clinicians to consider fracture risk at the time of
prescribing prednisone and similar drugs. Indeed, it has
been shown (4) that on the first day of prednisone Rx,
bone formation markers will be suppressed. Even injec-
tions into joints can affect bone turnover markers for 2 wk
or more (5).
Challenges of Short-Term Management
of GIOP
From the known effects of GIOP, it is obvious that the
astute clinician must deal with the fact that institution of
glucocorticoid treatment that will likely last for at least
1 more quires thinking about bone status. Interestingly, the
new guideline from the American College of Rheumatol-
ogy (ACR) (6) recommends that evaluation and, possi-
bly, treatment be accomplished within 6 mo of beginning
glucocorticoid treatment. If the recent study by Waljee et al
(3) demonstrating increased fracture risk within a month
of starting glucocorticoid treatment is confirmed, then im-
mediate osteoporosis risk evaluation and potentially start-
ing concomitant osteoporosis treatment will need to be
considered. Thus, the first challenge in short-term manage-
ment of GIOP is recognition by prescribers that even short-
term glucocorticoid therapy may increase fracture. The list
of clinicians who prescribe glucocorticoids is long: primary
care clinicians, rheumatologists, pulmonologists, neurolo-
gists, allergists, dermatologists, gastroenterologists, endo-
crinologists, and oncologists, among others. Patients seeking
the help of these various clinicians usually have symptom-
atic problems that bring them to medical attention, such
as a flare of rheumatoid arthritis, an exacerbation of chronic
obstructive pulmonary disease, or a worsening of mul-
tiple sclerosis. The focus of the clinician is the underlying
problem and choosing therapy to alleviate the symptoms.
The clinician has little time to evaluate the patient, order
tests, choose a therapeutic option, write prescriptions,
educate the patient, and then document everything that has
been done. Thus, there is no time to review guidelines on
possible bone side effects of the glucocorticoid treat-
ment. There are several guidelines and they may be com-
plicated or even conflicting (discussed later in the text).
Hence, it is not surprising that the majority of patients have
no attention paid to potential fracture risk. If the clini-
cian believes that the glucocorticoid therapy will be for only
a short time, it provides a possibly false sense of security
that there will be no increase in fracture risk, should the
clinician even consider it.
Importance of Bone Density and Vertebral
Fracture Assessment in GIOP
It is important to remember that the classic fractures of
GIOP are in the spine. Trabecular bone loss in the spine
often leads to much lower spine bone mineral density
(BMD) compared with femoral neck BMD. This should be
recognized because the ACR Guideline utilizes both dual
energy X-ray absorptiometry (DXA) and FRAX (10-yr
fracture risk calculator) to characterize fracture risk. FRAX
uses femoral neck BMD and cannot be calculated using
spine BMD. So, a patient who has a spine T-score of −2.4
but a low risk by FRAX based on a relatively good femoral
neck BMD might not be considered for treatment despite
remaining on prednisone.Trabecular bone score of the spine
(7) may also be helpful in determining which patients on
oral glucocorticoids are more likely to fracture. Interest-
ingly, in a study (8) of teriparatide vs alendronate therapy
for GIOP, only those patients treated with the anabolic agent
had an improvement in trabecular bone score after therapy.
Other modalities should also be utilized in evaluating the
patient at risk of GIOP. Decreases in height and images
of the spine can identify cryptic vertebral fractures. Whereas
classic X-rays of the thoracic and lumbar spine can be de-
finitive, for many patients, vertebral fracture assessment by
DXA is an option (9). This much lower radiation dose tech-
nique provides an image of the lateral spine up to about
T5 and can calculate changes in vertebral height.The finding
of a compression fracture with osteopenia or low bone mass
(or even normal BMD) should, in most cases, lead the cli-
nician to order pharmacologic therapy for the patient on
oral glucocorticoids.
Challenges of Long-Term Management
of GIOP
Some patients will require months to years of glucocor-
ticoid therapy at doses known to increase fracture risk.
As shown in the United Kingdom General Practice Re-
search Database study (2), fracture risk is clearly evident
at 3 mo and continues to increase within the duration of
treatment. Both current and cumulative doses (10,11) appear
to influence fracture risk, with 10–15 mg daily of predni-
sone equivalent the threshold at which risk seems to in-
crease dramatically. Consequently, that varied group of
clinicians must again recognize the risk and decide on an
approach to management. If lower doses lead to fewer frac-
tures, it is of course reasonable for the prescriber to lower
the dose of glucocorticoid, but the balance between
symptom or disease relief and side effects may be diffi-
cult. So-called steroid-sparing therapies may be adminis-
tered, such as biologics for rheumatoid arthritis and inhaled
glucocorticoids for chronic bronchitis or asthma. The bio-
logics have their own side effects and are expensive; in some
settings inexpensive prednisone may be the only choice.
High-dose inhaled glucocorticoids (12) in asthma particu-
larly, may have an impact on bone similar to that of oral
glucocorticoids. Flares of the underlying disorder may lead
to bursts of higher dose glucocorticoids.
There are 2 further challenges in long-term glucocorti-
coid therapy. First, the side effects of some bone-active medi-
cations may be more likely in patients on prednisone or

Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume ■, 2018
 ARTICLE IN PRESS
Glucocorticoid-Induced Osteoporosis in Older Patients
its equivalent. For example, the 2 most feared side effects
of bisphosphonates are osteonecrosis of the jaw (ONJ) and
atypical femoral fractures (AFF). In both cases, patients on
bisphosphonates and oral glucocorticoids appear to be at
higher risk of these side effects than patients only on
bisphosphonates (13,14). Because the mechanisms under-
lying these increased risks may not be clear, they add to
the complexity of management. In addition, information
about the long-term use of drugs such as bisphosphonates,
regardless of the cause of osteoporosis, is limited. Al-
though there is no definite association between the dura-
tion of bisphosphonate and ONJ (13), it is reasonable to
assume that the patient who remains on bisphosphonate
because of GIOP is at higher risk than the patient with
GIOP who is not receiving bisphosphonate therapy. On the
other hand, the preponderance of evidence (15,16) sug-
gests that duration of bisphosphonate therapy is associ-
ated with increased incidence of AFF, the most feared
complication. So, if risk of fracture in GIOP is related to
cumulative dose of glucocorticoid and if side effects of
GIOP therapy are related to duration of bisphosphonate
therapy, then the patient on long-term prednisone equiva-
lent is faced with potential problems whether GIOP is
treated or not. Clinicians must choose management based
on individualized fracture risk and side effects risk
assessment.
Solutions to the Challenges of GIOP for
Patients Older Than 50
Medical organizations have addressed challenges with
regard to GIOP in patients older than 50 in the form of
guidelines. Among several available guidelines are 2 that
are directed specifically at GIOP. All guidelines recom-
mend minimization of glucocorticoid dose, a nutritious diet
with adequate calcium and vitamin D [(supplements of
vitamin D if needed), and general osteoporosis measures,
such as avoidance of smoking and home safety. The Inter-
national Osteoporosis Foundation (IOF) recommends (17)
that all patients over 70 yr of age who are taking 7.5 mg
of prednisolone (or equivalent) or having had an osteo-
porotic fracture should be considered for osteoporosis treat-
ment. For patients ages 50–70 yr, the IOF recommends that
fracture risk calculator FRAX be used to determine if os-
teoporosis treatment should be considered. Each country
can determine the threshold for treatment. Despite the rela-
tively low cost of teriparatide in Europe compared with the
United States, the cost is still 1 or 2 orders of magnitude
higher for the anabolic drug than for oral bisphosphonates
(see further), leading to the likely use of more inexpen-
sive agents for most patients.
The ACR recently updated its guideline (6). It also uti-
lizes the FRAX calculation for determining eligibility for
treatment, but the ACR Guideline is much more compli-
cated than that of the IOF. Using FRAX, preferably cal-
culated with a BMD by DXA, the ACR divided patients
into low-, medium-, and high-risk groups. High risk was
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health
3
defined as a hip or spine BMD T-score of ≤−2.5 or a dose-
adjusted FRAX risk of ≥20% for major osteoporotic frac-
ture (MOF) or ≥3% for hip fracture. Dose adjustment was
as follows: for doses >7.5 mg of prednisone equivalent daily,
the MOF fracture risk should be increased by 15% and the
hip fracture risk by 20%. Moderate risk was defined as a
10-yr MOF risk of 10%–19% and a hip fracture risk of
1.1%–2.9%, with both doses adjusted. Pharmacologic
therapy was suggested for these 2 groups. Low-risk pa-
tients were defined as an MOF risk of <10% and a hip frac-
ture risk of ≤1% in 10 yr. These patients can be treated
conservatively with adequate dietary calcium and vitamin
D, with supplements of the latter if necessary. All patients
need repeated assessment every 1–3 yr, if they remain on
glucocorticoid therapy.
For the moderate- and high-risk patients, the ACR rec-
ommended oral bisphosphonates because randomized, con-
trolled trials (e.g., see References 18 and 19.) demonstrated
morphometric fracture risk reduction in subjects treated
with these preparations. Two recent observational studies
(20,21) have confirmed that oral bisphosphonates reduce
clinical fractures. Thomas et al (20) found that alendronate
and risedronate lowered both vertebral and nonvertebral
fractures in GIOP. In a study from Sweden (21), there was
a dramatic absolute fracture risk reduction in older pa-
tients on prednisone equivalents and alendronate com-
pared with similar patients not on alendronate. The ACR
recommended oral bisphosphonates as first-line therapy for
GIOP because of their known efficacy and general safety,
as well as their long experience and low cost. Alterna-
tives included intravenous bisphosphonates, teriparatide,
denosumab, and raloxifene (for postmenopausal women
only). In a randomized comparator trial (22), intravenous
zoledronic acid increased BMD to a greater extent than
oral risedronate, but the trial was too small to show any
difference in fracture risk reduction. In another trial (23),
teriparatide increased BMD by DXA more than risedronate
did. Interestingly, using high resolution quantitative com-
puted tomography, teriparatide improved both trabecu-
lar and cortical bone compared with risedronate. Although
there were clinical fractures in the patients treated with
risedronate and none in the group treated with teriparatide,
the study (23) was too small to make any conclusions. Years
ago, Saag et al (24) did a 3-yr trial demonstrating that
teriparatide increased BMD more than alendronate and
importantly lowered the number of fractures experi-
enced by the participants to a significant degree. Using a
large insurance database, Overman et al (25) reported that
patients on prednisone for more than 90 d and patients
taking any osteoporosis medication assessed (alendronate,
ibandronate, risedronate, zoledronic acid, teriparatide, or
denosumab) were found to have suffered fewer fractures
than patients not taking any of these osteoporosis medi-
cations. The conclusion from these studies is that osteopo-
rosis therapy works well in GIOP. The choice of therapy
is of interest as well.Anabolic agents make physiologic sense
because of the pathophysiology of GIOP. Teriparatide
Volume ■, 2018
 ARTICLE IN PRESS
4 Adler
appears to stimulate osteoblasts, which have been turned
off by glucocorticoids.The comparator studies would suggest
that anabolic treatment is superior to antiresorptive therapy
in GIOP. Nonetheless, the ACR chose to recommend oral
bisphosphonates as first-line therapy. The ACR Guide-
line’s determination of oral bisphosphonates as primary
therapy can be used by third-party payers in requiring choice
of such drugs as first-line therapy. For many patients, in-
travenous bisphosphonates may diminish problems with
drug adherence, and anabolic treatment may lead to fewer
fractures.
Recent studies in postmenopausal osteoporosis
strengthen the argument that anabolic therapy should be
considered as the first treatment choice for high-risk pa-
tients with GIOP. In the DATA-SWITCH study (26), Leder
et al showed that BMD would actually decrease when 2yr
of antiresorptive therapy with denosumab was followed by
teriparatide. Conversely, 2 yr of teriparatide followed by
denosumab resulted in a vigorous increase in BMD.
These data argue against waiting to show that a patient
failed antiresorptive therapy before starting anabolic treat-
ment. In the recently reported 2-yr VERO trial in post-
menopausal women(27), subjects treated with teriparatide
had fewer fractures than those treated with risedronate.
These studies and those of Gluer et al (23) and Saag et al
(24) in GIOP provide evidence for greater use of ana-
bolic therapy first for patients with the highest risk of frac-
ture. However, 2 factors temper enthusiasm for wider use
of teriparatide: the need for a daily subcutaneous injec-
tion and cost. In most cases, it is the cost—ranging from
about $500 monthly in Europe to $3000 monthly in the
United States—that is the limiting factor. There are special
programs established to mitigate the out-of-pocket costs
for some patients. A new anabolic agent, abaloparatide,
which may be more potent than teriparatide (28), has been
approved for postmenopausal osteoporosis in the United
States. There are no studies of this drug in GIOP, but its
mechanism of action is similar to that of teriparatide.
Abaloparatide has a lower wholesale price in the United
States, but whether it will be low enough to increase use
in GIOP, especially because such use would be off-label at
this point, remains to be seen. Of note, teriparatide,
abaloparatide, and raloxifene have not been linked to the
side effects that worry patients the most, ONJ and AFF.
Treatment Works, but Patients Are Not Treated
The previously mentioned review of treatment studies
provide convincing evidence that fractures in GIOP can be
reduced by osteoporosis medication, even those drugs that
appear to be less efficacious. The problem remains that pa-
tients at risk are not treated. The publication of guide-
lines has had little impact on practice, and only a minority
of patients at risk of GIOP are treated. Several interven-
tions have been tried to improve adherence to guidelines
for GIOP, including education of clinicians, interventions
aimed at the patients, and reminders in electronic medical
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health
records. None of the interventions has had much success.
As reported in a publication from an international meeting
(29), the potential solution to the lack of recognition of
GIOP fracture risk was found in a previous study. In the
mostly closed Geisinger Medical System, a comprehen-
sive program (30) was established to identify and evalu-
ate patients at risk of osteoporotic fracture, including those
on glucocorticoids. By finding patients at risk of fracture,
which included review of electronic medical records to dis-
cover patients on oral glucocorticoids, the staff at Geisinger
evaluated and treated patients at risk, resulting in fewer
fractures and great savings in suffering and money. In the
United Kingdom, Fracture Liaison Services (FLS) have been
formed to find patients who have fractures and make sure
they are evaluated and treated for underlying osteoporo-
sis to prevent second fractures. A growing number of
medical centers in the United States have also instituted
FLS. Patients who have fractures are identified from elec-
tronic medical records, allowing the FLS coordinator, who
is usually a nurse or nurse practitioner, to arrange appro-
priate evaluation and treatment. FLS leads to fewer frac-
tures (31) and, in at least 1 study, fewer deaths (32). The
FLS coordinator should also be the GIOP coordinator and
receive a list of patients on chronic prednisone equiva-
lents. Each medical center can decide the specific target
population, which could range from individuals with a 30-d
prescription to a 6-mo prescription of glucocorticoid. De-
pending on the specific medical center, the extra burden
on the FLS coordinator could be large and might even
justify another person. One could envision the GIOP co-
ordinator also assessing patients on androgen depriva-
tion therapy, aromatase inhibitors, or enzyme inducing
antiseizure drugs. Whereas a GIOP coordinator would have
to have a scope of practice that would allow ordering DXA
testing and perhaps prescribing osteoporosis treatment, the
program would have to have acquiescence from the many
different clinicians who order glucocorticoid Rx. It is the
author’s opinion that busy clinicians would be very happy
to have a GIOP coordinator shoulder the responsibility of
the increased fracture risk from GIOP. Further studies to
demonstrate this impact would be of great benefit.
In conclusion, knowledge is important, but application
of the knowledge is necessary to improve health in older
individuals. GIOP needs to be recognized, and a GIOP co-
ordinator using lists of patients provided by electronic
medical records would help in this recognition. With the
help of an osteoporosis expert at each institution, care-
fully choosing an osteoporosis treatment will also lead to
fewer fractures, less suffering, and lower cost in the long
run.
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