Glucocorticoids osteonecrosis

In 15 men with osteonecrosis of the femoral head after short-term therapy the mean duration of therapy was 21 (range 7-39) days and the mean dose in milligram equivalents of prednisone was 850 (range 290-3300) mg (269). The time from administration of glucocorticoids to hip pain was 17 (range 6-33) months. A new case of bilateral avascular necrosis of the femoral heads after high-dose short-term dexamethasone therapy as an antiemetic in cancer chemotherapy has been reported (270). 

Osteonecrosis of the femoral head can occur with glucocorticoids in nonpregnant individuals, but has not previously been reported in pregnancy (376). 

Osteonecrosis of the femoral head after the use of a glucocorticoid nasal spray has been reported (445). 

Intra-articular and periarticular administration Local injections of glucocorticoids into and around the joints can have a dramatic therapeutic effect, but the catabolic effect can have serious consequences, including adverse effects on joint structure (461) and on local tendons, subcutaneous atrophy, and possibly osteonecrosis. Provided the state of the joint is carefully inspected before any new injection is given, and the interval between the injections is not less than 4 weeks, the risk seems to be small enough to justify treatment in invalidating cases (SEDA-3, 307). 

Both of the polymorphisms described here are associated with greater sensitivity to glucocorticoids. It is not known whether these glucocorticoid receptor gene polymorphisms are causally related to osteonecrosis. However, these variants are present in combination in only 1% of the normal Caucasian population. 

In a review of 71 case series the weighted mean time to event and the minimum reported time and dose of zoledronate, pamidronate, and oral bisphosphonates was calculated [13 ]. The mean time to osteonecrosis after zoledronate treatment was 1.8 years and the minimum 10 months after pamidronate, the mean time was 2.8 years and the minimum 1.5 years after oral bisphosphonate therapy, the mean time was 4.6 years and the minimum 3 years. The factors that affected the risk of osteonecrosis and the time to event were invasive dental procedures and other co-morbid factors, such as advanced age, rheumatoid arthritis, diabetes, use of glucocorticoids, and vitamin D deficiency. 

Most cases of bisphosphonate-related osteonecrosis occur after intravenous administration of bisphosphonate treatment for malignant bone disease and metastatic cancer. As the incidence of osteonecrosis caused by oral administration is low, it is believed that bisphosphonates are relatively safe and effective in preventing the complications of osteoporosis, such as hip or spine fractures. Osteonecrosis caused by oral bisphosphonates has been described in five Asian women aged over 65 years [15 ]. Three had also used glucocorticoids for rheumatoid arthritis. Irrespective of race, the elderly women undergoing glucocorticoid therapy have an increased incidence of osteonecrosis even with oral bisphosphonates. 

There has been a report of Kienbock disease (osteonecrosis of the lunate bone) resulting from local glucocorticoid injections in a 51-year-old man [13" ]. 

Osteoporosis Several new reviews summarise the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis management, regulatory requirements and risk-assessment options 37, ] and also osteonecrosis [38 39, ]. 

Weinstein RS. Glucocorticoid-induced osteoporosis and osteonecrosis. Endocrinol Metab Clin North Am 2012 41(3) 595-611. 

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