Background Bone loss is a well-known side effect of glucocorticoid (GC) therapy, but its extent has been poorly quantified.

Objectives To investigate GC-induced bone loss in patients with chronic inflammatory diseases (low dose) or transplants (high dose) through a meta-analysis of cohorts.

Methods Data sources: A search of published studies in PubMed (1995 – 2012), Cochrane databases (1995 – 2012), EMBASE (1995 – 2012), and bibliographic references extending and expanding a previous systematic review on chronic disease [1] up to 2012.

Study selection Prospective studies were included of patients receiving GC who underwent at least two bone mineral density (BMD) measurements by dual x-ray absorptiometry over a period of at least 8 months. Only supplementation with calcium and/or Vitamin D3 was allowed. Cohorts studying patients using bisphosphonates or other anti-osteoporotic drugs or diseases associated with influence on bone loss were excluded. Primary outcome was the one-year change in lumbar spine BMD; secondary outcome the change in femoral neck BMD. Where applicable, data was linearly extrapolated or interpolated to estimate bone loss at one year, but only in the chronic inflammatory diseases group. In the transplantation group the last observation (no earlier than at 8 months) was carried forward

Data extraction and synthesis Of 5602 titles, 285 articles remained. In these, 44 articles with 51 relevant study arms studied chronic inflammatory diseases group (N=1565). Likewise 21 articles with 24 study arms were included in the transplantation group (N=679). GC dose is expressed as prednisolone equivalents. Review Manager v 5.1 calculated weighted means (inverse variance method); strong heterogeneity required application of the random effects model

Results In the chronic inflammatory diseases group (both starters and chronic users) the mean daily dose of GC was 8,8 mg (range 1.2 – 16.4). Bone loss at the lumbar spine was -1.8% [95%CI: -2.2; -1.3]; see graph. Only 39 cohorts (N=1255) also measured femoral neck; in these bone loss was -1.5% [-2.1; -0.9] in the lumbar spine, and -1.3% [-1.8; -0.8] in the femoral neck. In the transplantation group (almost all starters) the mean daily dose of GC was 20.4 mg (range 7.7 – 52.7). Bone loss at the lumbar spine was -4.9%[-6.6; -3.1]. Only 18 cohorts (N=551) also measured femoral neck; in these bone loss was -4.1% [-6.0; -2.2] in the lumbar spine, and -3 [-4.8; -1.3] in the femoral neck.

The graph depicts individual studies, weighted mean and 95%CI.

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Figure 1.

BMD % change from baseline.

Conclusions This meta-analysis provides definitive data on one-year bone loss across a range of diseases and GC doses. It shows GC treatment at the high doses used in transplantation patients leads to considerable bone loss, especially in the lumbar spine. In contrast, bone loss is limited during GC treatment at the lower doses used in chronic inflammatory disease. Existing guidelines should be updated to reflect this data.

References

1. Lodder MC, et al. Ann Rheum Dis 2003;62 (suppl 1):94.

Disclosure of Interest None declared

DOI 10.1136/annrheumdis-2014-eular.5036