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Am Fam Physician. 2000;61(8):2499

Even low-dose glucocorticoid therapy is now known to cause bone loss, especially trabecular bone loss. This loss is greatest during the first six months of glucocorticoid use but continues at a rate of up to 10 percent per year. This bone loss and its associated increased fracture risk occur in patients taking as little as 7.5 mg of prednisone daily. Calcium and vitamin D supplementation, hormone replacement therapy (HRT), calcitonin and bisphosphonates are used to maintain bone mass.

The American College of Rheumatology recommends that all patients taking glucocorticoids also take at least 1,500 mg of calcium and 800 IU of vitamin D every day. HRT is recommended in postmenopausal women. If HRT is contraindicated, bisphosphonates and calcitonin are the suggested alternates. Aagaard and colleagues conducted this retrospective review to determine whether these recommendations were being followed in a hospital outpatient clinic.

Adult outpatients who were receiving prednisone in a dosage of at least 5 mg daily for at least one month were included in the study. Medical charts were reviewed for history, lifestyle factors associated with an increased risk of osteoporosis, comorbidities, fracture history and evidence of any medication (or discussion of such a medication) being given as prophylaxis against glucocorticoid-induced osteoporosis. There were 215 patients receiving glucocorticoids (median dosage: 10 mg). Most of these prescriptions were made following diagnoses of pulmonary or rheumatic conditions. Common comorbid conditions were hypertension, anemia, hepatitis, diabetes mellitus and coronary artery disease. Calcium and vitamin D were the most commonly prescribed prophylactic agents (42 and 37 percent, respectively). A combination of these two was prescribed in 30 percent of patients. HRT was given to 57 percent of postmenopausal patients who were eligible for this treatment. Bisphosphonates were used in 4 percent of patients; none were given calcitonin.

Men and premenopausal women were especially unlikely to receive osteoporosis prophylaxis. Women were 1.7 times more likely to receive some form of prophylaxis, and patients with rheumatic disease were also more likely to receive this preventive therapy. Overall, only 58 percent of the patients who were studied received prophylaxis of any kind. The authors conclude that physicians remain unaware or unconvinced of the need for prophylaxis of glucocorticoid-induced osteoporosis, and that further education is needed.

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