These recommendations are based on the Royal College of Physicians guideline, Glucocorticoid-induced osteoporosis [RCP, 2002].

Bisphosphonates

• The evidence on bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis is less robust than for postmenopausal osteoporosis. The RCP summarized the evidence on treatments for corticosteroid-induced osteoporosis and concluded that the efficacy of bisphosphonates varies, but beneficial effects on bone mineral density (BMD) in the spine and hip have been demonstrated. Fracture was not a primary endpoint of any study, but a reduction in vertebral fracture was observed in post-hoc or safety analyses of trials of etidronate, alendronate, and risedronate.

Calcium and vitamin D

• The RCP summarized the evidence on calcium and vitamin D supplements in corticosteroid-induced osteoporosis and concluded that calcium plus vitamin D supplementation improves spine and proximal femur BMD, but the evidence is inconsistent. The effect on vertebral fracture risk has not been adequately assessed.

Vitamin D analogues (alfacalcidol and calcitriol)

• If a bisphosphonate is contraindicated or is not tolerated, the person may be started on alfacalcidol or calcitriol. CKS considers that since these drugs are rarely prescribed in primary care, advice should be sought from a specialist.
• The RCP summarized the evidence on vitamin D analogues and concluded that it is inconsistent regarding effects on BMD and fracture. A later meta-analysis of 54 trials indicated that vitamin D₃ analogues are more effective than no treatment, placebo, plain vitamin D₃, and/or calcium at decreasing the risk of vertebral fractures [de Nijs et al, 2004]. Bisphosphonates, however, are more effective than vitamin D₃ analogues at preserving bone density and decreasing the risk of vertebral fractures.

Zoledronic acid

• Zoledronic acid has recently been licensed for the treatment of steroid-induced osteoporosis [ABPI Medicines Compendium, 2009]. Since it is a once-yearly infusion, it could be considered in people with problems with delayed oesophageal emptying, people who are unable to sit or stand upright for 30 minutes after taking a bisphosphonate, or those with active or recent gastrointestinal problems. However, since it is an infusion, it can only be given in secondary care.

Monitoring calcium levels

• The advice to check serum calcium levels if hypocalcaemia or hypercalcaemia is suspected before or during treatment reflects advice in the summaries of product characteristics for bisphosphonates and preparations containing calcium and vitamin D [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2008].