Abstract
Oral glucocorticoids (GCs) are widely used and despite their adverse effects on bone mineral density, the risk of sustaining osteoporotic fractures is not well addressed. The objective of this retrospective, cohort study was to assess fracture risk in patients exposed to oral GCs. Patients from an administrative claims database who were prescribed oral GCs and were enrolled 1 year before and 1 year after the initial oral GC claim were matched with a comparison population on age, sex, and date of first claim. Measurements of exposure included amount, duration, and pattern of oral GC use. The osteoporosis-related risk of fracture was based on the ratio of hazard functions estimated using a Cox proportional hazards model. The adjusted relative risk (RR) estimates (and 95% CI) for fractures were hip 1.87 (95% CI, 1.2 to 2.9), vertebral 2.92 (95% CI, 2.0 to 4.3), wrist/forearm 1.03 (95% CI, 0.8 to 1.4), nonvertebral 1.68 (95% CI, 1.5 to 1.9), any fracture 1.75 (95% CI, 1.6 to 1.9). A dose dependence of fracture risk was observed for hip, vertebral, nonvertebral, and any fractures. Long duration and continuous pattern of GC use demonstrated a significant 5-fold increased risk of hip and 5.9-fold increased risk of vertebral fracture. The combined effect of higher dose, longer duration, and continuous pattern further increased RR estimates to 7-fold for hip and 17-fold for vertebral fractures. This study confirms previous observations that suggest oral GCs have a rapid deleterious effect on trabecular-rich bone. The emerging relationship between amount, duration, and pattern of oral GC exposure and fracture risk should be considered in clinical practice and managed care settings to avoid the debilitating effects of fractures in patients.
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Laan RFJM, van Riel PLCM, van Erning LJTO et al (1992) Vertebral osteoporosis in rheumatoid arthritis patients: effect of low dose prednisone therapy. Br J Rheumatol 31:91–96
Buckley LM, Leib ES, Cartularo KS, Vacek PM, Cooper SM (1995) Effects of low dose corticosteroids on the bone mineral density of patients with rheumatoid arthritis. J Rheumatol 22:1055–1059
Laan RFJM, van Riel PLCM, van de Putte LBA et al (1993) Low-dose prednisone induces rapid reversible axial bone loss in patients with rheumatoid arthritis: a randomized, controlled study [see comments]. Ann Intern Med 119:963–968
Sambrook P, Birmingham J, Kempler S et al (1990) Corticosteroid effects on proximal femur bone loss. J Bone Miner Res 5:1211–1216
Reid IR, Evans MC, Stapleton J (1992) Lateral spine densitometry is a more sensitive indicator of glucocorticoid-induced bone loss. J Bone Miner Res 7:1221–1225
Hooyman JR, Melton LJ III, Nelson AM, O’Fallon WM, Riggs BL (1984) Fractures after rheumatoid arthritis: a population-based study. Arthritis Rheum 27:1353–1361
Cooper C, Coupland C, Mitchell M (1995) Rheumatoid arthritis, corticosteroid therapy and hip fracture. Ann Rheum Dis 54:49–52
Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C (2000) Use of oral corticosteroids and risk of fractures. J Bone Miner Res 15:993–1000
Luengo M, Picado C, Del Rio L et al (1991) Vetebral fractures in steroid dependent asthma and involutional osteoporosis: a comparative study. Thorax 46:803–806
Adinoff AD, Hollister JR (1983) Steroid-induced fractures and bone loss in patientes with asthma. N Engl J Med 309:265–268
Lems WF, Jahangier ZN, Jacobs JWG, Bijlsma JWJ (1995) Vertebral fractures in patients with rheumatoid arthritis treated with corticosteroids. Clin Exp Rheumatol 13:293–297
Als OS, Gotfredsen A, Christiansen C (1985) The effect of glucocorticoids on bone mass in rheumatoid arthritis patients. Arthritis Rheum 28:369–375
Ruegesegger P, Medici TC, Anlinker M (1983) Corticosteroid-incuded bone loss: a longitudinal study of alternate day therapy in patients with bronchial asthma using quantitative computed tomography. Eur J Clin Pharmacol 25:615–620
Garton MJ, Rein DM (1993) Bone mineral density of the hip and of the anteroposterior and lateral dimensions of the spine in men with rheumatoid arthritis. Arthritis Rheum 36:222–228
de Deuxchaisnes CN, Devogelaer JP, Esselinckx W et al (1984) The effect of low dosage glucocorticoids on bone mass in rheumatoid arthritis: a cross-sectional and a longitudinal study using single photon absorptiometry. Adv Exp Med Biol 171:209–239
Butler RC, Davie MWJ, Worsfold M, Sharp CA (1991) Bone mineral content in patients with rheumatoid arthritis: relationship to low-dose steroid therapy. Br J Rheumatol 30:86–90
Reid DM, Nicoll JJ, Smith MA et al (1986) Corticosteroids and bone mass in asthma: comparisons with rheumatoid arthritis and polymyalgia rheumatica. Br Med J 293:1463–1466
Hahn TJ, Halstead R, Teitelbaum SL, Hahn BH (1979) Altered mineral metabolism in glucocorticoid-induced osteoporosis: effect of 25-hydroxyvitamin D administration. J Clin Invest 64:655–665
Greenberger PA, Hendrix RW, Patterson R, Chmiel JS (1982) Bone studies on patients on prolonged systemic cortocosteroid therapy for asthma. Clin Allergy 12:363–368
Verstraeten A, Dequeker J (1986) Vertebral and peripheral bone mineral content and fracture incidence in postmenopausal patients with rheumatoid arthritis: effect of low dose corticosteroids. Ann Rheum Dis 45:852–857
Naganathan V, Jones G, Nash P et al (2000) Vertebral fracture risk with long-term corticosteroid therapy. Arch Intern Med 160:2917–2922
Dykman TR, Gluck OS, Murphy WA, Hahn TJ, Hahn BH (1985) Evaluation of factors associated with glucocorticoid-induced osteopenia in patients with rheumatic diseases. Arthritis Rheum 28:361–368
Sambrook PN, Eisman JA, Champion GD, Yeates MG, Pocock NA (1987) Determinants of axial bone loss in rheumatoid arthritis. Arthritis Rheum 30:721–728
Van Staa TP, Leufkens HG, Cooper C (2002) The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporos Int 13:777–787
Michel BA, Bloch DA, Wolfe F, Fries JF (1993) Fractures in rheumatoid arthritis: an evaluation of associated risk factors. J Rheumatol 20:1666–1669
Ramsey-Goldman R, Dunn JE, Huang C-F et al (1999) Frequency of fractures in women with systemic lupus erythematosus: comparison with United States population data. Arthritis Rheum 42:882–890
Van Staa TP, Cooper C, Barton I et al (2002) Predictors for vertebral fracture and fracture threshold in patients using oral corticosteroids. Arthritis Rheum 46[Suppl 9]:S585
American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. Arthritis Rheum 44:1496–1503
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Some of the findings of this study were presented in Abstract form at the World Congress on Osteoporosis in 2000. That Abstract was published in Osteoporosis Int (2000) 11[suppl 2]:S114. This study was supported by Procter & Gamble Pharmaceuticals (Cincinnati, OH, USA).
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Steinbuch, M., Youket, T.E. & Cohen, S. Oral glucocorticoid use is associated with an increased risk of fracture. Osteoporos Int 15, 323–328 (2004). https://doi.org/10.1007/s00198-003-1548-3
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DOI: https://doi.org/10.1007/s00198-003-1548-3