Osteoporosis with corticosteroids

Rizzoli R, Chevalley T, Slosman DO, Bonjour JP. Sodium monofluorophosphate increases vertebral bone mineral density in patients with corticosteroid-induced osteoporosis. Osteoporos Int 1995 5(l) 39-46. 

Corticosteroids are available in tablet, inhaled and intravenous dosage forms. Inhaled corticosteroids allow the control of asthma with minimal systemic absorption and thus reduce the risks associated with corticosteroids such as osteoporosis and adrenal suppression. These risks are greatly increased when taking systemic corticosteroids. 

Schacht, E. (1999). Rationale for treatment of involutional osteoporosis in women and for prevention and treatment of corticosteroid-induced osteoporosis with alfacalddol. Calcif. Tissue Int. 65,317-327. 

Rizzato G, Tosi G, Mella C, et al. Prednisone-induced bone loss in sarcoidosis a risk especially frequent in postmenopausal women. Sarcoidosis 1988 5 93 98. Gallacher SJ, Fenner JA, Anderson K, et al. Intravenous pamidronate in the treatment of osteoporosis associated with corticosteroid dependent lung disease an open pilot study. Thorax 1992 47 932-936. 

GonneUi S, Rottoh P, CepoUaro C, et al. Prevention of corticosteroid-induced osteoporosis with alendronate in sarcoid patients. Calcif Tissue Int 1997 61 382-385. Rizzato G, Montemurro L. Reversibility of exogenous corticosteroid-induced bone loss. Eur Respir J 1993 6 116 119. 

Patients with IBD, particularly those with CD, are also at risk for bone loss. This may be a function of malabsorption or an effect of repeated courses of corticosteroids. Patients with IBD should receive a baseline bone density measurement prior to receiving corticosteroids. Vitamin D and calcium supplementation should be used in all patients receiving long-term corticosteroids. Oral bisphosphonate therapy may also be considered in patients receiving prolonged courses of corticosteroids or in those with osteopenia or osteoporosis. 

One chronic adverse effect that is of concern is osteoporosis.32,33 Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, and valproate have all been shown to decrease bone mineral density, even after only 6 months of treatment. Data on the relationship between other AEDs and osteoporosis are not currently available. Multiple studies have shown the risk of osteoporosis due to chronic AED use to be similar to the risk with chronic use of corticosteroids. Patients taking carbamazepine, phenytoin, phenobarbital, or valproate for longer than 6 months should take supplemental calcium and vitamin D. Additionally routine monitoring for osteoporosis should be performed every 2 years, and patients should be instructed on ways to protect themselves from fractures. 

Prednisone -corticosteroid -leukocytosis -nausea and vomiting indigestion -anorexia or increased appetite -CNS effects (depression, anxiety, euphoria, insomnia, psychosis, confusion) -fluid retention -hyperglycemia -osteoporosis -acne -adrenal insufficiency with prolonged use... 

Guidelines for managing corticosteroid-induced osteoporosis recommend measuring BMD at the beginning of chronic therapy (prednisone 5 mg or more daily or equivalent for at least 6 months) and followup monitoring with DXA in 6 to 12 months. BMD should be measured in patients taking chronic therapy whose baseline values were not obtained. 

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Deltacortil is a proprietary preparation of the corticosteroid prednisolone. As with other corticosteroids, prednisolone may lead to precipitation of osteoporosis, insomnia and candidiasis. 

Speciai risk Use with caution in the following situations Nonspecific ulcerative colitis if there is a probability of impending perforation, abscess, or other pyogenic infection diverticulitis fresh intestinal anastomoses hypertension CHF thromboembolitic tendencies thrombophlebitis osteoporosis exanthema Cushing syndrome antibiotic-resistant infections convulsive disorders metastatic carcinoma myasthenia gravis vaccinia varicella diabetes mellitus hypothyroidism, cirrhosis (enhanced effect of corticosteroids). 

Spontaneous reports of osteoporosis, osteopenia, bone fractures, and delayed healing of bone fractures have been seen in the isotretinoin population. While causality to isotretinoin has not been established, an effect cannot be ruled out. Physicians should use caution when prescribing isotretinoin to patients with a genetic predisposition for age-related osteoporosis, a history of childhood osteoporosis conditions, osteomalacia, or other disorders of bone metabolism. This would include patients diagnosed with anorexia nervosa and those who are on chronic drug therapy that causes drug-induced osteoporosis/osteomalacia and/or affects vitamin D metabolism, such as systemic corticosteroids and any anticonvulsants. 

Adverse reactions of corticosteroids are frequent with the long-term immunosuppressive regimens which are often needed and include an increased risk of infections, Cushing-like symptoms, hypertension, hyperglycemia, osteoporosis, growth retardation in children and mental reactions such as dysphoria, psychosis and depression. 

Osteoporosis is a metabolic bone disease characterized by low bone mass and micro-architectural deterioration of bone tissue. This will lead to bone fragility and consequent increase in bone fracture risk. Mean bone mineral density (BMD) is measured with dual X-ray absorptiometry (DEXA) and expressed in Tsc (Tscore). WHO standards are a Tsc that is 1 standard deviation (SD) below mean BMD is graded as normal bone, Tsc between 1 and 1.5 SD below mean BMD is graded as osteopenia and a Tsc of more than 2.5 SD below mean BMD is graded as osteoporosis. When the Tsc is below 1.5 SD mean BMD prevention of osteoporosis must be initiated. Primary osteoporosis is caused mainly by hormone deflciency in both women and men. Secondary osteoporosis may result from endocrine, metabolic, nutritional and autoimmune causes or from immobility because of trauma. Also the use of medicaments such as corticosteroids may be contributing. 

Sato S, Ohosone Y, Suwa A, Yasuoka H, Nojima T, Fujii T, Kuwana M, Nakamura K, Mimori T, Hirakata M. Effect of intermittent cyclical etidronate therapy on corticosteroid induced osteoporosis in Japanese patients with connective tissue disease 3 year follow up. J Rheumatol 2003 30 2673-9. 

Samaras K, Pett S, Gowers A, McMurchie M, Cooper DA. Iatrogenic Cushing s syndrome with osteoporosis and secondary adrenal failure in human immunodeficiency virus-infected patients receiving inhaled corticosteroids and ritonavir-boosted protease inhibitors six cases. J Clin Endocrinol Metab 2005 90(7) 4394-8. 

Corticosteroids should be used cautiously in the presence of congestive heart failure, myocardial infarction, hypertension, diabetes mellitus, epilepsy, glaucoma, hepatic disorders, osteoporosis, peptic ulceration, and renal impairment. Children are more susceptible to these adverse effects. To avoid cardiovascular collapse, steroids must be given slowly by intravenous injection. Large doses produce Cushing s syndrome (with moon face and sometimes hirsutism). 

Inhaled corticosteroids should be prescribed for patients with an FEVi of 50% predicted or less, who have two or more exacerbations needing treatment with antibiotics or oral corticosteroids a year. Warn patients about the possible risk of osteoporosis and other side effects of high-dose inhaled corticosteroids. None of the inhaled corticosteroids currently available is licensed alone for use in COPD. 

Osteoporosis is also common in those on long-term corticosteroid therapy (for example patients with autoimmune hepatitis or coexisting inflammatory bowel disease). Patients with chronic liver disease may also have other risk factors for osteoporosis related to their disease state. These include vitamin D deficiency, excessive alcohol consumption, poor diet, physical inactivity and low body mass index. Oestrogen deficiency in the postmenopausal stage further increases the risk. 

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