Controlling Bone Loss When Taking Steroids

Many people with inflammatory diseases take glucocorticoids, such as prednisone, to control the inflammation. Unfortunately, long-term glucocorticoid (steroid) use can lead to several unwanted side effects, including bone density loss and osteoporosis. In fact, the most common cause of secondary osteoporosis is steroid use.

What Problem Was Studied?

Current international guidelines recommend bisphosphonate medications for people who already have or are at risk for developing steroid-induced osteoporosis. However, another drug currently in use to reduce risk of fracture for people with osteoporosis is teriparatide – a recombinant human parathyroid hormone. While bisphosphonates work by preventing the absorption of bone, teriparatide works by stimulating bone formation.

Endocrinology Basics

Recombinant human parathyroid hormone: A synthetic form of the naturally occurring parathyroid hormone, which is the primary regulator of calcium metabolism in bone and kidney. It controls bone formation and resorption, reabsorption of calcium in kidneys, and calcium absorption in intestines. Daily injections of the recombinant form stimulates new bone formation.

An international team of scientists, led by Kenneth G. Saag, MD, of the University of Alabama at Birmingham, designed and carried out a randomized clinical trial comparing teriparatide (Forteo) with alendronate (Fosamax; a commonly used bisphosphonate) for the treatment of steroid-induced osteoporosis. Although Dr. Saag has received several Arthritis Foundation research grants unrelated to this particular project, this trial was sponsored by Eli Lilly, the maker of Forteo. In the New England Journal of Medicine article, Dr. Saag assures readers of the independence of the findings, “All authors participated in the interpretation of the data and the decision to publish the findings, had unrestricted access to the data, were not limited by the sponsor with regard to statements made, and vouch for the veracity and completeness of the data.”

What Was Done in the Study?

A total of 428 people with established steroid-induced osteoporosis participated in the trial. They were randomly assigned to receive either 20 micrograms of teriparatide via injection plus an oral placebo tablet or 10 milligrams of oral alendronate plus an injectable placebo. All participants also received calcium and vitamin D supplements. Bone mineral density (BMD) was determined via dual-energy X-ray absorptiometry (DEXA) at baseline and at one, three, six, 12 and 18 months.

What Were the Study Results?

People with steroid-induced osteoporosis in the teriparatide group had an increase in BMD twice the increase found in the alendronate group. Lumbar spine density increased by 7.2 percent in the teriparatide group compared with 3.4 percent in the alendronate group. There were fewer spine fractures in those receiving teriparatide. Adverse events were similar between the two groups.

What Does This Mean for People Taking Steroids?

“Because some patients having arthritis, lupus or other rheumatic disease may require steroid medications, protecting your bones is very important,” said Dr. Saag. The study authors also concluded that although the standard of care for people at risk for steroid-induced bone loss includes antiresorptive agents, such as alendronate, certain patients with or at high risk for steroid-related osteoporosis may need more aggressive therapy. They further suggest, “Teriparatide might be considered as a therapeutic strategy for patients at high risk for fracture.”

Saag KG, Shane E, Boonen S, et al. Teriparatide or alendronate in gludocorticoid-induced osteoporosis. N Engl J Med 2007;357:2028-39.

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