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Bisphosphonates May Be Underprescribed in Corticosteroid Users

January 26, 2006

People with chronic skin diseases who take oral corticosteroids long-term may be at increased risk for bone-loss-related problems, according to a study showing that doctors do not always adequately address the risk of bone loss in this patient population.

The study by Liu and colleagues was published in the Archives of Dermatology and reported by MedPage Today on January 16, 2006.

At one dermatology center, 80% of people receiving corticosteroid therapy for dermatological disease were not taking bisphosphonates, thereby raising their risk of bone fractures and osteoporosis, said Victoria P Werth of the University of Pennsylvania, according to MedPage Today.

Clinical Trial

The cross-sectional study included 35 men and women who had chronic skin disease for which they were taking prednisone (10 mg/day or more) or an equivalent drug. Participants were in their mid-50s, mostly white and had been taking prednisone for 17 months on average.

Of the 35 participants, 28 (80%) were taking no bisphosphonate prior to their referral. Bone mineral density scans for 18 participants showed that seven had normal bone mineral density, eight were osteopenic and three were osteoporotic.

The results agreed with those of previous studies, which suggested that most people who receive long-term glucocorticoid therapy have low bone mineral density and that more than 25% suffer bone fractures. In these people, the greatest loss of bone mass occurs during the first six months of corticosteroid therapy, and the risk of fracture increases greatly within the first three months.

Guidelines for Bisphosphonates

The American College of Rheumatology (ACR) guidelines were updated in 2001 to recommend that doctors prescribe bisphosphonate therapy for all patients receiving long-term prednisone (5 mg/d or more), according to MedPage Today. However, equivalent guidelines do not exist for dermatologists.

The authors wrote, "our study demonstrated a dramatic underuse of bisphosphonates by our referral physicians, which was not influenced by the publication of the ACR guidelines."

They recommended that, "Unless there is a specific contraindication, bisphosphonates should be prescribed concomitantly with the initiation of corticosteroid therapy in diseases for which long-term glucocorticoid use is anticipated as part of the standard care."

The two FDA-approved bisphosphonates used to treat glucocorticoid-induced osteoporosis are Merck's Fosamax (alendronate) and Procter & Gamble's Actonel (risedronate), both of which are available in a once-weekly oral formulation.

The researchers also noted that patients should undergo a baseline bone mineral density assessment, as well as taking calcium and vitamin D supplements, although the evidence that they help to prevent fractures is mixed. Although generally well tolerated, bisphosphonates should be used with caution in pre-menopausal women, as the drugs increase the risk of fetal skeletal abnormalities, according to the researchers.

The study was supported by grants from the National Institutes of Health and Procter & Gamble.

Posted: January 2006