Arthritis Rheum. 2001 Jul;44(7):1496-503. doi: 10.1002/1529-0131(200107)44:7<1496::AID-ART271>3.0.CO;2-5.
Glucocorticoid-induced bone loss should be prevented, and if present, should be treated (Table 2). Supplementation with calcium and vitamin D at a dosage of 800 IU/day, or an activated form of vitamin D (e.g., alfacalcidiol at 1 microg/day or calcitriol at 0.5 microg/day), should be offered to all patients receiving glucocorticoids, to restore normal calcium balance. This combination has been shown to maintain bone mass in patients receiving long-term low-to-medium-dose glucocorticoid therapy who have normal levels of gonadal hormones. However, while supplementation with calcium and vitamin D alone generally will not prevent bone loss in patients in whom medium-to-high-dose glucocorticoid therapy is being initiated, supplementation with calcium and an activated form of vitamin D will prevent bone loss. There are no data available to support any conclusion about the antifracture efficacy of the combination of calcium supplementation plus an activated form of vitamin D. Antiresorptive agents are effective in the treatment of glucocorticoid-induced bone loss. All of these agents either prevent bone loss or modestly increase lumbar spine bone mass and maintain hip bone mass. While there are no randomized controlled trials of prevention of glucocorticoid-induced bone loss or radiographic vertebral fracture outcomes with HRT or testosterone, patients receiving long-term glucocorticoid therapy who are hypogonadal should be offered HRT. The bisphosphonates are effective for both the prevention and the treatment of glucocorticoid-induced bone loss. Large studies have demonstrated that bisphosphonates also reduce the incidence of radiographic vertebral fractures in postmenopausal women with glucocorticoid-induced osteoporosis. Treatment with a bisphosphonate is recommended to prevent bone loss in all men and postmenopausal women in whom long-term glucocorticoid treatment at > or =5 mg/day is being initiated, as well as in men and postmenopausal women receiving long-term glucocorticoids in whom the BMD T-score at either the lumbar spine or the hip is below normal. While there is little information on the prevention or treatment of bone loss in premenopausal women, these women, too, may lose bone mass if they are being treated with glucocorticoids, so prevention of bone loss with antiresorptive agents should be considered. If bisphosphonate therapy is being considered for a premenopausal woman, she must be counseled regarding use of appropriate contraception. The therapies to prevent or treat glucocorticoid-induced bone loss should be continued as long as the patient is receiving glucocorticoids. Data from large studies of anabolic agents (e.g., PTH) and further studies of combination therapy in patients receiving glucocorticoids are eagerly awaited so additional options will be available for the prevention of this serious complication of glucocorticoid treatment.
应预防糖皮质激素所致的骨质流失，若已出现则应进行治疗（表2）。应向所有接受糖皮质激素治疗的患者补充钙和维生素D，剂量为每日800国际单位，或补充活性维生素D（如阿法骨化醇每日1微克或骨化三醇每日0.5微克），以恢复正常的钙平衡。已证明这种联合用药可使接受长期低至中等剂量糖皮质激素治疗且性腺激素水平正常的患者维持骨量。然而，虽然单独补充钙和维生素D通常无法预防开始接受中至高剂量糖皮质激素治疗患者的骨质流失，但补充钙和活性维生素D可预防骨质流失。目前尚无数据支持关于补充钙加活性维生素D联合用药抗骨折疗效的任何结论。抗吸收药物对治疗糖皮质激素所致的骨质流失有效。所有这些药物要么预防骨质流失，要么适度增加腰椎骨量并维持髋部骨量。虽然尚无关于激素替代疗法（HRT）或睾酮预防糖皮质激素所致骨质流失或影像学椎体骨折结局的随机对照试验，但对于接受长期糖皮质激素治疗且性腺功能减退的患者，应给予HRT。双膦酸盐对预防和治疗糖皮质激素所致的骨质流失均有效。大型研究表明，双膦酸盐还可降低患有糖皮质激素所致骨质疏松症的绝经后女性影像学椎体骨折的发生率。对于所有开始接受每日≥5毫克长期糖皮质激素治疗的男性和绝经后女性，以及腰椎或髋部骨密度T值低于正常水平且正在接受长期糖皮质激素治疗的男性和绝经后女性，建议使用双膦酸盐治疗以预防骨质流失。虽然关于绝经前女性骨质流失的预防或治疗信息较少，但这些女性若接受糖皮质激素治疗也可能会骨质流失，因此应考虑使用抗吸收药物预防骨质流失。若考虑对绝经前女性进行双膦酸盐治疗，必须就使用适当避孕措施对其进行咨询。只要患者在接受糖皮质激素治疗，就应持续采用预防或治疗糖皮质激素所致骨质流失的疗法。急切期待关于促合成代谢药物（如甲状旁腺激素）的大型研究数据以及对接受糖皮质激素治疗患者联合治疗的进一步研究结果，以便能有更多选择来预防糖皮质激素治疗的这一严重并发症。
