Chronic glucocorticoid use can lead to osteoporosis and fractures by reducing bone formation and increasing bone resorption. Glucocorticoids exert these effects by binding to receptors in bone cells and inhibiting osteoblast proliferation and stimulating osteoblast apoptosis. This decreases calcium absorption and increases calcium excretion, resulting in bone loss. High glucocorticoid doses like 21 mg per day can cause 27% lumbar spine bone density loss in a year and increase fracture risk within 3-6 months. Prevention focuses on reducing glucocorticoid dose and duration when possible, calcium/vitamin D supplementation, bisphosphonates, and exercise.

1. DR.Y.SASIKUMAR

2. Chronic glucocorticoid excess has
deleterious effects on bone that
can lead to osteoporosis and
fractures.

3. GLUCOCORTICOIDS AND BONE PHYSIOLOGY
 Glucocorticoids reduce bone formation and
increase bone resorption.
 Glucocorticoids exert their effects on gene
expression via cytoplasmic glucocorticoid
receptors.
 In adult bone, glucocorticoid receptors are
found in stromal cells & osteoblasts

4. Decreased bone formation —
 The predominant effect of glucocorticoids on
the skeleton is reduced bone formation.
 The decline in bone formation may be
mediated by direct inhibition of osteoblast
proliferation and by stimulation of apoptosis
of osteoblasts .

5. Decreased calcium absorption —
 Glucocorticoids decrease intestinal calcium
absorption
Increased calcium excretion —
 Glucocorticoids increase renal calcium
excretion by decreasing calcium reabsorption
The effects are pronounced with daily
therapy, may be less with alternate-day
therapy.

6. CLINICAL ASPECTS OF GLUCOCORTICOID-
INDUCED BONE LOSS
 A prospective, longitudinal study found that
patients beginning high-dose glucocorticoid
therapy (mean dose 21 mg/day) lost a mean
of 27% of their lumbar spine bone density
during the first year.
 There is a substantial increase in fracture risk
in patients receiving glucocorticoid therapy
that appears within three to six months of
initiating treatment.
 Fracture risk appears to be related to the
dose and duration of therapy.

7.  Bone density usually increases after
discontinuation of exogenous glucocorticoids

8. Prevention and treatment of
glucocorticoid-induced osteoporosis
GENERAL MEASURES —
 Attempts to reverse the glucocorticoid
excess by decreasing the dose of
exogenous glucocorticoid
 The glucocorticoid dose and the
duration of therapy should be as low
as possible.

9.  When glucocorticoids are given, topical therapy
(such as inhaled glucocorticoids for asthma &
glucocorticoid enemas for bowel disease) is
preferred.
 Consider short-term high-dose pulse therapy
instead of continuous therapy for weeks or
months .
 Patients should be encouraged to do weight-
bearing exercises for at least 30 minutes each
day .
 Patients should avoid smoking and excess
alcohol.

10. CALCIUM AND VITAMIN D
The American College of Rheumatology (ACR)
recommends the following
 Maintain a calcium intake of 1000 to 1500
mg/day
 Vitamin D intake of 800 IU/day

11. BISPHOSPHONATES - (Eg- ALENDRONATE,
ETIDRNATE)
 These drugs prevent glucocorticoid-induced
bone loss by prolonging the lifespan of
osteoblasts.
 Total body bone density increased
significantly with the alendronate treatment.

12. The American College of Rheumatology (ACR)
guidelines recommends the following interventions
in patients initiating prednisone in a dose of 5
mg/day or higher for more than three months and
for patients receiving long term glucocorticoids in
whom the BMD T-score is below -1.0.
 • Bisphosphonate therapy alendronate 35
mg/week for prevention, 70 mg/week for treatment
 Consideration of calcitonin therapy if
bisphosphonates are contraindicated or not
tolerated.( dose of 200 IU/day)

13. CONTRA-INDICATIONS
 Abnormalities of oeaophagus –
Eg-stricture,Achalasia.
 Hypocalcemia
 Preganancy & Breast-feeding

14. SIDE-EFFECTS
 Peptic ulceration
 Abdominal pain & distension
 Dyspepsia & regurgitation
 Osteonecrosis of the jaw

15. Patient information
 Drugs need to be taken in the morning on an
empty stomach with a full 8 oz glass of plain
water.
 The person must then wait for at least half an
hour before eating or taking any other
medications.
 These dosing instructions help to reduce the
risk of side effects and potential
complications.

16. THANK YOU