Glucocorticoids remain to be among the most important and most frequently used anti-inflammatory and immunosuppressive or immune-modulatory acting drugs to treat rheumatic (and other) diseases. Unfortunately, glucocorticoids also exert undesired effects, especially if higher dosages have to be given over longer periods of time. In this regard, cardiovascular, gastro-intestinal, dermatological, ophthalmological, and metabolic adverse effects, the increased risk of infection, the incidence of a Cushingoid phenotype, and in particular glucocorticoid-induced osteoporosis (GIOP) are to be mentioned.
However, the available data describing frequency and severity of these adverse effects are fragmentary. For example, it is difficult to distinguish specific adverse effects of a glucocorticoid therapy from other causations (e. g., the treated disease itself, other concomitant diseases or concomitant therapies). This statement is especially true for GIOP in the context of chronic inflammatory rheumatic diseases, since GIOP is counted among the two most important adverse effects of glucocorticoid therapy, by both rheumatologists and patients. This top (negative) ranking of GIOP stands in sharp contrast to the state of knowledge and scientific data, being sparse, partly conflicting and often derived from over-aged projects or studies.
With regard to the pathophysiology of GIOP it seems clear, however, that glucocorticoids contribute to early and rapid bone loss and increased fracture risk which is mediated by direct effects on osteoblasts (decreased bone formation), osteoclasts (increased bone resorption) and osteocytes (increased apoptosis and sclerostin levels), and indirect effects through alterations in gonadal hormones and the neuromuscular system (Rizzoli & Biver, Nat Rev Rheum, 2015).
With regard to the management of GIOP, general preventive measures comprise using the lowest possible GC dose, good nutrition with sufficient intake of calcium, vitamin D, regular weight-bearing exercise, the avoidance of tobacco use and alcohol abuse and other recommendations.
The treatment of GIOP consists of an early introduction of anti-osteoporotic therapy for patients receiving glucocorticoid therapy who are at increased risk of fracture. This treatment should be continued as long as the glucocorticoid dose is above intervention thresholds or fracture risk is increased. (Rizzoli & Biver, Nat Rev Rheum, 2015).
Disclosure of Interest F. Buttgereit Grant/research support from: Horizon Pharma, Consultant for: Horizon Pharma, Mundipharma, Pfizer, Speakers bureau: Horizon Pharma, Mundipharma, Pfizer