SNOWMASS, COLO. — In the absence of clear indications for bisphosphonate therapy to prevent bone loss in long-term corticosteroid users, all patients prescribed corticosteroids should be advised to take vitamin D and calcium supplements, Dr. Lenore Buckley said at a symposium sponsored by the American College of Rheumatology.
Whether a patient is a long-term, low-dose corticosteroid user or a new user starting at a high dosage, “calcium and vitamin D supplements make a big difference,” said Dr. Buckley, a professor in the division of rheumatology at the Medical College of Virginia, Richmond. Supplementation appears to cut bone loss by at least 50%, she added.
Dr. Buckley followed a cohort of 65 rheumatoid arthritis patients who were taking an average of 5 mg of prednisone a day for 1 year. Those who received calcium and vitamin D supplementation had a mean 0.7% gain in bone mineral density in the lumbar spine, while those who did not use the supplements lost a mean of 2% (Ann. Intern. Med. 1996;125:961–8).
In a study of alendronate in patients taking an average of 7.5 mg of prednisone per day, those assigned to alendronate had increases in bone density measures. Nevertheless, the placebo group, which received only vitamin D and calcium supplements, still had no change in lumbar-spine bone mineral density over 2 years (N. Engl. J. Med. 1998;339:292–9). The same was true at the trochanter, and somewhat at the femoral neck.
Physician surveys suggest that rheumatologists do somewhat better than other specialists at tracking bone deterioration associated with corticosteroids. Still, patient surveys suggest that less than half of long-term steroid users take vitamin D and calcium supplementation, Dr. Buckley said.
Bisphosphonate therapy has been shown to protect bone density and should be considered for some patients taking corticosteroids, but it is not exactly clear when it needs to be instituted, Dr. Buckley said. The American College of Rheum-atology recommends considering bisphosphonates for any adult taking more than 5 mg of prednisone, or the equivalent, daily for more than 3 months. However, not all guidelines are in agreement with this advice.
Patient surveys suggest that less than half of long-term steroid users take vitamin D and calcium supplementation. DR. BUCKLEY