University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma.
Hospital for Special Surgery, New York, New York.
Arthritis Rheumatol. 2023 Dec;75(12):2088-2102. doi: 10.1002/art.42646. Epub 2023 Oct 16.
The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily.
An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included.
This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
本指南旨在更新针对接受糖皮质激素（GC）治疗≥3 个月、每日剂量≥2.5mg 的风湿性或非风湿性疾病患者，预防和治疗糖皮质激素诱导性骨质疏松症（GIOP）的建议。
针对非药物治疗、药物治疗、停药和序贯治疗的临床问题，进行了更新的系统文献回顾。采用推荐评估、制定与评价（GRADE）方法对证据的确定性进行分级。投票小组对推荐的方向（支持或反对）和强度（强烈或有条件）达成了≥70%的共识。
对于开始或继续接受 GC 治疗>3 个月的成年人，我们强烈建议在开始 GC 治疗后尽快进行骨折风险的初始评估，包括临床骨折评估、骨密度评估（采用椎体骨折评估或脊柱 X 射线）和 Fracture Risk Assessment Tool（如果年龄≥40 岁）。对于中、高或极高骨折风险的成年人，我们强烈建议进行药物治疗。口服或静脉用双膦酸盐、地舒单抗或甲状旁腺激素类似物的选择应通过共同决策做出。对于高和极高骨折风险的患者，建议将合成代谢剂作为初始治疗选择。本指南还针对特殊人群（包括儿童、器官移植患者、可能怀孕的患者和接受高剂量 GC 治疗的患者）提出了建议。本指南还包括关于停药和序贯治疗的新建议。
本指南为临床医生和患者在制定治疗决策以管理 GIOP 方面提供了指导。这些建议不应被用来限制或拒绝使用治疗方法。
