In this study, we aimed to evaluate and compare the treatment indication for patients with glucocorticoid-induced osteoporosis (GIOP) in various clinical practice guidelines.
We searched for potentially relevant studies conducted from January 2000 to March 2020 using online databases, including PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, KoreaMed, KMbase, and KoMGI. We reviewed and analyzed the guidelines that included recommendations on GIOP and fulfilled the inclusion criteria.
A total of 94 articles were selected based on review of the title and abstract; 14 guidelines were assessed upon reviewing the full text. The bone mineral density score for therapeutic intervention of GIOP in postmenopausal women was presented in 7 guidelines, among which 3 guidelines set a T-score of −2.5 or lower and the other 4 guidelines proposed a less stringent cut-off point of −1.5 or lower. Among the 10 guidelines published since 2012 after the emergence of the fracture risk assessment tool (FRAX), 6 guidelines included FRAX in their criteria for defining intervention thresholds. However, they were further divided into fixed-probability (n=3) and age-dependent (n=3) thresholds based on the country.
Recently developed guidelines use FRAX as the criterion for establishing the treatment of patients with GIOP. However, these intervention thresholds need to be adapted for each country.
Glucocorticoids (GCs) are used in a wide range of clinical settings and play a major role in the treatment of various inflammatory diseases.[
Long-term GC use is associated with loss of bone density and deterioration of bone microstructure leading to increased fracture risk, primarily in the trabecular bones such as vertebrae.[
Numerous guidelines for the management of GIOP patients have been published and updated by each country and academic society.[
The Korean GIOP guidelines were recently developed by adapting established guidelines from other countries, but intervention thresholds had not been fully investigated.[
We conducted a comprehensive search for relevant studies published from January 2000 to February 2020 using electronic databases. The databases included PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, and 3 Korean databases (KoreaMed, KMbase, and KoMGI).
The search strategy was based on the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and followed the literature search process from the Korean GIOP guideline.[
Studies were included in this review if they met all of the following criteria: (1) identified themselves as guidelines; (2) contained recommendations for GC users; (3) provided intervention thresholds for GIOP; and (4) were in accordance with evidence-based methods. Studies were excluded if they (1) did not involve humans; (2) were limited to pediatric patients or a specific group of patients such as those with cancer, endocrine diseases, or human immunodeficiency virus infection; (3) were developed by a single author without appropriate representation or were based on simple consensus without systematic search; and (4) were not written in English or Korean. Potentially relevant papers were assessed for eligibility by screening the title and abstract, and then they were finally selected after full-text review on the basis of the predefined selection criteria. When there were several editions of guidelines from the same organization, the most recent one was selected. The literature searching and selection process was initially performed by 1 review author (THL) and subsequently checked by the other author (YJS). Disagreements were resolved by discussion between the 2 authors (THL and YJS).
The quality of the development process in the guidelines was assessed using the domain for “rigor of development” in the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.[
We extracted data from each included guideline pertaining to the characteristics of the guidelines (e.g., development organization, year of publication, applicable country or region, scope of osteoporosis, patient group), recommendations related to initial fracture risk assessment, recommendations related to intervention thresholds, and recommendations related to follow-up fracture risk assessment.
The recommendations for the assessment of clinical risk factors, such as falls, frailty, malnutrition, weight loss or low body weight, history of alcohol use or smoking, and other clinical comorbidities were omitted in this review, and we examined mainly instrumental assessments, i.e., bone mineral density (BMD) or FRAX. In addition, data on the drugs for osteoporosis treatment were not extracted.
Considering the study design of this review, where meta-analysis or statistical analysis was not appropriate, a narrative synthesis of data to summarize and describe systematic review results was conducted. The investigation of similarities and differences between guidelines, and comparison of recommendations related to the topic were undertaken. Then, further analysis of the supporting evidence reflected in determining intervention thresholds was followed.
The flow diagram in
The characteristics of the 14 selected guidelines are summarized in
The thresholds for initiating anti-osteoporosis intervention in patients receiving or starting long-term GC therapy are based on the following criteria: GC dose and duration of use, age, prior fragility fracture, BMD score using dual energy X-ray absorptiometry (DXA), and FRAX score (
The scores for the AGREE II rigor of development of the included guidelines varied considerably, ranging from 12% to 75% with an average score of 28% (with the exception of the Dachverband Osteologie e.V. [DVO] guidelines, whose development process was only available in German) (
However, because the AGREE instrument primarily reflects the process involved in asking key questions with respect to “with what agent,” it was difficult to clearly assess the evidence for determining the thresholds for “who to treat.” Thus, we examined and described the intervention thresholds from all 14 guidelines in detail, rather than reviewing only the guidelines that we considered to be rigorously developed.
The recommendations extracted from the guidelines for initial fracture risk assessment in the management and prevention of GIOP are shown in
Five guidelines, which were mostly published before 2012, propose BMD assessment as a single tool for identifying individuals at high risk for fractures.[
The recommendations in most guidelines discuss postmenopausal women and men aged over 50 or 60. The guidelines from the ACR and the KSBMR/KCR present recommendations for younger patients separately. They suggest that BMD should be checked in adults under 40 who are at high fracture risk due to a history of previous osteoporotic fracture or a significant accompanying osteoporosis risk factor.[
We extracted the recommendations for thresholds based on FRAX and BMD and the details of GC use from the guidelines (
A dose greater than 5 or 7.5 mg of prednisone equivalents per day with a 3-month minimum duration was proposed as a threshold for preventive therapy in most guidelines.[
Of the 7 guidelines which include BMD score as a threshold for pharmacological therapy for postmenopausal women, 4 guidelines proposed a T-score threshold of −1.5 or less.[
For FRAX, the intervention thresholds in each guideline are divided into age-dependent thresholds and fixed-thresholds. Adjustments of FRAX for GC dose and BMD values (if available) are consistently recommended in the guidelines. The International Osteoporosis Foundation and the European Calcified Tissue Society (IOF-ECTS), SFR/GRIO, and NOGG guidelines adopted an age-dependent approach to intervention thresholds.[
We identified the recommendations from 10 guidelines regarding the reassessment of fracture risk for individuals who continue GC treatment (
We reviewed recommendations with regard to intervention thresholds in both GIOP-specific guidelines and overall osteoporosis guidelines. Although recommendations are based on the rationale that the association of fracture risk with GCs is exposure-dependent, thresholds vary among the guidelines. The criteria for defining intervention thresholds were refined in accordance with the development of fracture risk assessment tools. Before the introduction of FRAX, intervention thresholds were based on the degree of GC exposure or BMD score. However, over time, the criteria for identifying patients who should receive preventive treatment has shifted towards country-specific FRAX values.
Previous epidemiological studies have demonstrated that the increased risk of vertebral and nonvertebral fracture is related to GC dose and exposure.[
The conventional BMD T-score of −2.5 is usually applied to the guidelines for postmenopausal osteoporosis treatment; however, some guidelines apply less stringent T-score values because the fracture risk is much higher in GIOP compared to that expected based on DXA values.[
However, the higher BMD cut-off point is not an evidence-based threshold, but rather an accepted value considering the discrepancy between BMD data and fracture data in GC users. It is unclear whether (and to what degree) the less stringent BMD threshold predicts fracture risk in individuals using GCs, and whether it is cost-effective in terms of drug therapy. Therefore, a more comprehensive approach beyond the BMD which considers various clinical risk factors for fracture is particularly important in GIOP.[
The recognition that consideration of independent risk factors and BMD together is more accurate in predicting fracture probability compared to BMD alone has led to the development of fracture risk tools that incorporate various clinical risk factors, including oral GCs.[
The dose relationship between GC use over 3 months and fracture risk can be employed in the FRAX model, which allows the estimates to be adjusted depending on GC dose.[
In spite of these adjustments to overcome the limitations of the conventional FRAX algorithm, FRAX makes no distinction between past and current GC use and lacks the ability to estimate fracture risk in premenopausal women and men under 40. In addition, its predictive value for identifying individuals at high risk of fracture has been primarily validated for hip fractures.[
Recently updated recommendations have suggested less stringent FRAX cut-off points than those for postmenopausal osteoporosis for determining when anti-osteoporosis intervention is in order.[
The discrepancies between the 2 main guidelines on GIOP arise from diversity in local conditions, such as health care policies, cost of treatment, and accessibility to BMD, as well as different fracture probabilities across the countries. However, the majority of guidelines, especially using a fixed-FRAX probability, have adopted an identical threshold value as the USA, without their own health economic analysis.[
In Korea, the 2018 guidelines for GIOP prevention and treatment contain the accepted thresholds of FRAX and BMD which were suggested by the ACR. Given the lack of domestic data, the working group decided to adapt previously published guidelines and presented the same intervention thresholds from the 2017 ACR guidelines.[
Despite a sensitive search strategy for eligible guidelines, explicit selection criteria for eligibility, and appraisal of the guidelines using the AGREE II instrument, several limitations could have biased our findings. First, only guidelines written in English were included, and guidelines written in other languages may have been overlooked. Second, the National Guideline Clearinghouse, which is a public resource of evidence-based clinical practice guidelines and widely used for guideline searching, was not included in the search database because it was not available at the time of the literature search. Thus, we might have missed some eligible guidelines. Third, the quality of the evidence underpinning the recommendations was not investigated because the AGREE instrument evaluates the methodological rigor and transparency with which a guideline is developed and not the quality of its contents. Moreover, statements of the strengths and limitations of data in the guidelines were mainly concerned with anti-osteoporosis drugs. For this reason, a comprehensive investigation of previous studies supporting the recommendations was performed to identify the evidence underpinning the effectiveness of thresholds for therapeutic intervention in the current GIOP guidelines.
In conclusion, the results of our review showed that GIOP guidelines have proposed thresholds distinct from those of postmenopausal osteoporosis, given the natural history of bone loss caused by GCs. Since the introduction of FRAX, a FRAX-based approach has been incorporated into the criteria for defining intervention thresholds. However, high-quality data pertaining to these thresholds that can warrant intervention in GC-treated patients are still limited. Further studies assessing fracture as a primary outcome with established tools, such as FRAX and DXA, in chronic GC users could aid in setting tailored intervention thresholds in GIOP guidelines.
Search strategies for PubMed and Ovid-EMBASE
No. | Search query | Results |
---|---|---|
PubMed | ||
#1 | steroid[MeSH terms] | 846,711 |
#2 | steroid*[TIAB] OR glucocorticoid*[TIAB] | 288,429 |
#3 | #1 OR #2 | 1,001,632 |
#4 | osteoporosis[MeSH terms] | 54,846 |
#5 | osteoporos*[TIAB] OR osteopenia[TIAB] | 72,023 |
#6 | “bone loss” OR “bone losses” | 35,264 |
#7 | #4 OR #5 OR #6 | 113,146 |
#8 | #3 AND #7 | 15,903 |
#9 | practice guideline[PT] OR guideline[PT] OR guideline*[TI] OR recommendation*[TI] OR standard*[TI] | 215,924 |
#10 | #8 AND #9 | 265 |
#11 | animals[MeSH terms] NOT humans[MeSH terms] | 4,670,734 |
#12 | #10 NOT #11 | 256 |
#13 | Limit #12 to yr=“2000-current” | 233 |
| ||
Ovid-EMBASE | ||
#1 | steroids.mp. or exp steroid/ | 1,464,935 |
#2 | glucocorticoids.mp. or exp glucocorticoid/ | 702,802 |
#3 | (steroid* or glucocorticoid*).tw. | 383,900 |
#4 | #1 OR #2 OR #3 | 1,546,020 |
#5 | osteoporosis.mp. or exp osteoporosis/ | 150,197 |
#6 | osteoporos*.tw. | 99,514 |
#7 | osteopenia.mp. or exp osteopenia/ | 23,259 |
#8 | osteopenia.tw. | 15,161 |
#9 | bone loss.mp. or exp bone loss/ | 87,819 |
#10 | bone loss*.tw. | 36,627 |
#11 | #5 OR # 6 OR #7 OR #8 OR #9 OR #10 | 220,345 |
#12 | #4 AND #11 | 46,021 |
#13 | (guideline* or recommendation*).ti. | 143,716 |
#14 | #12 AND #13 | 718 |
#15 | limit #14 to human | 677 |
#16 | limit #15 to yr=”2000-Current” | 618 |
Standardized Appraisal of Guidelines for Research and Evaluation II (AGREE II) domain score for rigor of development in each guideline. a)Excluded from the assessment because the development process was provided in German only. SER, Spanish Society of Rheumatology; KSBMR/KCR, Korean Society for Bone and Mineral Research/Korean College of Rheumatology; ACR, American College of Rheumatology; NOGG, National Osteoporosis Guideline Group; SIOMMMS, Società Italiana dell’Osteoporosi del Metabolismo Minerale e delle Malattie dello Scheletro; SEIOMM, Sociedad Española de Investigación Ósea y Metabolismo Mineral; SFR/GRIO, French Society for Rheumatology and Osteoporosis Research and Information Group; JSBMR, Japanese Society for Bone and Mineral Research; IOF-ECTS, International Osteoporosis Foundation and the European Calcified Tissue Society; SBR/BMA/ABMFR, Brazilian Society of Rheumatology/Brazilian Medical Association/Brazilian Association of Physical Medicine and Rehabilitation; DVO, Dachverband Osteologie e. V.; BBC, Belgium Bone Club; RCP, Royal College of Physicians.
Summary of development methodologies of the guidelines with the AGREE II rigor score of 50% or above
References | Guideline | Year | Method to search for evidence | Method to formulate recommendations | Method to evaluate the quality of evidence |
---|---|---|---|---|---|
Park et al. [ |
KSBMR/KCR | 2018 | Systematic review of published guidelines | Expert consensus | AGREE II |
Buckley et al. [ |
ACR | 2017 | Systematic review of RCTs | Expert consensus based on a voting process using Poll Everywhere software | Cochrane risk of bias tool |
Compston et al. [ |
NOGG | 2017 | Systematic review (review of RCTs, systematic review, meta-analyses) | Not mentioned | AMSTAR |
Papaioannou et al. [ |
Osteoporosis Canada | 2010 | Systematic review (review of published RCTs, cohort studies, systematic reviews, meta-analyses) | Expert consensus based on a modified RAND/University of California, Los Angeles Delphi method | Not mentioned |
Bone and Tooth Society of Great Britain et al. [ |
RCP | 2002 | Systematic review of RCTs | Not mentioned | Cochrane risk of bias tool |
KSBMR/KCR, Korean Society for Bone and Mineral Research/Korean College of Rheumatology; ACR, American College of Rheumatology; NOGG, National Osteoporosis Guideline Group; RCP, Royal College of Physicians; RCTs, randomized controlled trials; AGREE II, Appraisal of Guidelines for Research and Evaluation II; AMSTAR, Assessment of Multiple Systematic Reviews.
This research was supported by a grant of Patient-Centered Clinical Research Coordinating Center funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI19C0481, HC19C0047).
The review was exempted by the institutional review board of our university hospital because of the retrospective nature of our study, which used existing data or documents for research (IRB No. HYUH 2020-07-05).
No potential conflict of interest relevant to this article was reported.
Flow chart of the literature selection process. GIOP, glucocorticoid-induced osteoporosis.
Characteristics of guidelines on GIOP included in this review
References | Guideline |
Year |
Status | Country applied | Scope of OP | Independent criteria defining the intervention thresholds | |||||
---|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
OP overall | GIOP-specific | GC |
Age | Prior fracture | BMD | FRAX | |||||
Naranjo Hernández et al. [ |
SER | 2019 | Updated | Spain | √ | √ | √ | √ | √ | ||
| |||||||||||
Park et al. [ |
KSBMR/KCR | 2018 | New | South Korea | √ | √ | √ | √ | √ | ||
| |||||||||||
Buckley et al. [ |
ACR | 2017 | Updated | United States | √ | √ | √ | √ | √ | ||
| |||||||||||
Compston et al. [ |
NOGG | 2017 | Updated | United Kingdom | √ | √ | √ | √ | √ | √ | |
| |||||||||||
Rossini et al. [ |
SIOMMMS | 2016 | Updated | Italy | √ | √ | |||||
| |||||||||||
González-Macías et al. [ |
SEIOMM | 2015 | Updated | Spain | √ | √ | √ | √ | |||
| |||||||||||
Briot et al. [ |
SFR/GRIO | 2014 | Updated | France | √ | √ | √ | √ | √ | √ | |
| |||||||||||
Suzuki et al. [ |
JSBMR | 2014 | Updated | Japan | √ | √ | √ | √ | √ | ||
| |||||||||||
Lekamwasam et al. [ |
IOF-ECTS | 2012 | New | International | √ | √ | √ | √ | √ | √ | |
| |||||||||||
Pereira et al. [ |
SBR/BMA/ABMFR | 2012 | New | Brazil | √ | √ | |||||
| |||||||||||
Dachverband Osteologie e. V. [ |
DVO | 2011 | Updated | Germany, Austria, Switzerland | √ | √ | √ | ||||
| |||||||||||
Papaioannou et al. [ |
Osteoporosis Canada | 2010 | Updated | Canada | √ | √ | |||||
| |||||||||||
Devogelaer et al. [ |
BBC | 2006 | New | Belgium | √ | √ | |||||
| |||||||||||
Bone and Tooth Society of Great Britain et al. [ |
RCP | 2002 | New | United Kingdom | √ | √ | √ | √ |
Abbreviation of each guideline denotes the organization responsible for guideline development.
The most recent version of the guidelines was selected.
GC denotes prednisolone or equivalent, and includes obtaining a history with the details of glucocorticoid use (dose, duration, and pattern of use).
A fixed-probability threshold was adopted as an intervention threshold.
An age-dependent probability threshold was adopted as an intervention threshold.
GIOP, glucocorticoid-induced osteoporosis; SER, Spanish Society of Rheumatology; KSBMR/KCR, Korean Society for Bone and Mineral Research/Korean College of Rheumatology; ACR, American College of Rheumatology; NOGG, National Osteoporosis Guideline Group; SIOMMMS, Società Italiana dell’Osteoporosi del Metabolismo Minerale e delle Malattie dello Scheletro; SEIOMM, Sociedad Española de Investigación Ósea y Metabolismo Mineral; SFR/GRIO, French Society for Rheumatology and Osteoporosis Research and Information Group; JSBMR, Japanese Society for Bone and Mineral Research; IOF-ECTS, International Osteoporosis Foundation and the European Calcified Tissue Society; SBR/BMA/ABMFR, Brazilian Society of Rheumatology/Brazilian Medical Association/Brazilian Association of Physical Medicine and Rehabilitation; DVO, Dachverband Osteologie e. V.; BBC, Belgium Bone Club; RCP, Royal College of Physicians; OP, osteoporosis; GC, glucocorticoid; BMD, bone mineral density; FRAX, fracture risk assessment tool.
Initial fracture risk assessment and intervention thresholds for glucocorticoid users in the guidelines
References | Guideline | Year | Initial fracture risk assessment | Intervention thresholds |
---|---|---|---|---|
Naranjo Hernández et al. [ |
SER | 2019 | FRAX, BMD (if FRAX 10-year risk of major osteoporotic fracture ≥5%) | Postmenopausal women and men aged ≥50 years with GC ≥5 mg/day, BMD T-score ≤−1.5, FRAX 10-year risk of hip fracture ≥3%, FRAX 10-year risk of major osteoporotic fracture ≥10% without BMD, FRAX 10-year risk of major osteoporotic fracture ≥7.5% with BMD (All adults, prior fragility fracture, initial GC ≥30 mg/day) |
Park et al. [ |
KSBMR/KCR | 2018 | Adults aged ≥ 40 years, FRAX (GC-adjusted) |
Adults aged ≥40 years, BMD T-score ≤−2.5 (postmenopausal women and men aged ≥50 years), FRAX 10-year risk of major osteoporotic fracture ≥10%, FRAX 10-year risk of hip fracture >1% (All adults, prior fragility fracture, very high dose GCs |
Buckley et al. [ |
ACR | 2017 | Adults aged ≥ 40 years, FRAX (GC-adjusted) |
Adults aged ≥40 years, BMD T-score ≤−2.5 (postmenopausal women and men aged ≥50 years), FRAX 10-year risk of major osteoporotic fracture ≥10%, FRAX 10-year risk of hip fracture >1% (All adults, prior fragility fracture, very high dose GCs |
Compston et al. [ |
NOGG | 2017 | FRAX (GC-adjusted) |
Postmenopausal women and men aged ≥50 years, age ≥70 years, GC ≥7.5 mg/day, FRAX above intervention threshold (All adults, prior fragility fracture) |
Rossini et al. [ |
SIOMMMS | 2016 | DeFRA (GC-adjusted) | Postmenopausal women and men aged ≥50 years, GC ≥5 mg/day for ≥3 months |
González-Macías et al. [ |
SEIOMM | 2015 | NA | Postmenopausal women and men aged ≥50 years, GC dose ≥5 mg/day for ≥3 months |
Briot et al. [ |
SFR/GRIO | 2014 | BMD (GC use ≥3 months), VFA (GC ≥7.5 mg/day for ≥3 months) | Postmenopausal women and men aged ≥50 years, prior fragility fracture, age ≥70 years, GC ≥7.5 mg/day for ≥3 months, BMD T-score ≤−2.5, FRAX (GC-adjusted) |
Suzuki et al. [ |
JSBMR | 2014 | Score based on prior fragility fracture, age, GC dose, and lumbar spine BMD (% YAM) | Calculated individual patient’s score ≥3 |
Lekamwasam et al. [ |
IOF-ECTS | 2012 | FRAX (GC-adjusted) |
Postmenopausal women and men aged ≥50 years, prior fragility fracture, age ≥70 years, GC ≥7.5 mg/day for ≥3 months, BMD T-score ≤−1.5, FRAX above intervention threshold |
Pereira et al. [ |
SBR/BMA/ABMFR | 2012 | BMD | Postmenopausal women, GC ≥5 mg/day for ≥3 months |
Dachverband Osteologie e. V. [ |
DVO | 2011 | Women aged ≥50 years and men aged ≥60 years, BMD (if GC use ≥3 months) |
GC ≥7.5 mg/day for ≥3 months and BMD T-score ≤−1.5 |
Papaioannou et al. [ |
Osteoporosis Canada | 2010 | BMD (GC ≥7.5 mg/day for ≥3 months) | Adults aged >50 years, GC ≥7.5 mg/day for ≥3 months |
Devogelaer et al. [ |
BBC | 2006 | NA | GC ≥7.5 mg/day for ≥3 months |
Bone and Tooth Society of Great Britain et al. [ |
RCP | 2002 | BMD | GC use (any dose) ≥3 months, prior fragility fracture, age ≥65 years, BMD T-score ≤−1.5 |
If GC ≥7.5 mg/day, the risk of hip fracture is increased by 20% and the risk of a major osteoporotic fracture is increased by 15%.
If GC <2.5 mg/day, the risk of hip fracture is decreased by 35% and the risk of a major osteoporotic fracture is decreased by 20%, if GC ≥2.5 mg/day and <7.5 mg/day, no adjustment, and if GC ≥7.5 mg/day, risk of hip fracture is increased by 20% and major osteoporotic fracture is increased by 15%.
Defined as treatment with prednisone ≥30 mg/day and a cumulative dose of >5 g in the past year.
SER, Spanish Society of Rheumatology; KSBMR/KCR, Korean Society for Bone and Mineral Research/Korean College of Rheumatology; ACR, American College of Rheumatology; NOGG, National Osteoporosis Guideline Group; SIOMMMS, Società Italiana dell’Osteoporosi del Metabolismo Minerale e delle Malattie dello Scheletro; SEIOMM, Sociedad Española de Investigación Ósea y Metabolismo Mineral; SFR/GRIO, French Society for Rheumatology and Osteoporosis Research and Information Group; JSBMR, Japanese Society for Bone and Mineral Research; IOF-ECTS, International Osteoporosis Foundation and the European Calcified Tissue Society; SBR/BMA/ABMFR, Brazilian Society of Rheumatology/Brazilian Medical Association/Brazilian Association of Physical Medicine and Rehabilitation; DVO, Dachverband Osteologie e. V.; BBC, Belgium Bone Club; RCP, Royal College of Physicians; FRAX, fracture risk assessment tool; BMD, bone mineral density; GC, glucocorticoid; DeFRA, derived fracture risk assessment tool; NA, not available; VFA, Vertebral Fracture Assessment; YAM, young adult men.
Reassessment of fracture risk for prolonged glucocorticoids users in the guidelines
References | Guideline | Year | Follow-up fracture risk assessment |
---|---|---|---|
Naranjo Hernández et al. [ |
SER | 2019 | NA |
Park et al. [ |
KSBMR/KCR | 2018 | Adults aged ≥40 years, never treated with OP medication: FRAX with BMD every 1–3 years, during OP medication: BMD every 2–3 years at high risk |
Buckley et al. [ |
ACR | 2017 | Adults aged ≥40 years, never treated with OP medication: FRAX with BMD every 1–3 years, during OP medication: BMD every 2–3 years at high risk |
Compston et al. [ |
NOGG | 2017 | NA |
Rossini et al. [ |
SIOMMMS | 2016 | NA |
González-Macías et al. [ |
SEIOMM | 2015 | BMD at shorter intervals than postmenopausal OP |
Briot et al. [ |
SFR/GRIO | 2014 | BMD annually during the first 2 years, then adjusted interval according to the BMD values, GC dose, and underlying disease activity, spine X-ray or VFA if height loss ≥2 cm or with back pain |
Suzuki et al. [ |
JSBMR | 2014 | X-ray and BMD every 6–12 months |
Lekamwasam et al. [ |
IOF-ECTS | 2012 | BMD at appropriate intervals, X-ray or VFA if vertebral fracture suspected |
Pereira et al. [ |
SBR/BMA/ABMFR | 2012 | BMD, spine X-ray or VFA every 6 months during the first year of GC use, then every 1–2 years |
Dachverband Osteologie e. V. [ |
DVO | 2011 | BMD at intervals of 6–12 months in patients without OP medication, if GC ≥7.5 mg/day continued, BMD at shorter intervals (up to 6 months) in patients undergoing drug treatment, if GC ≥7.5 mg/day continued |
Papaioannou et al. [ |
Osteoporosis Canada | 2010 | BMD every 1–3 years |
Devogelaer et al. [ |
BBC | 2006 | NA |
Bone and Tooth Society of Great Britain et al. [ |
RCP | 2002 | Spinal BMD |
Individuals with very high-dose GCs, or fragility fracture occurring after ≥18 months of osteoporosis medication, poor medication adherence or absorption, or other osteoporosis risk factors.
Individuals with prior fragility fracture, or BMD Z-score <−3, ≥10% per year loss of BMD, very high-dose GCs, poor medication adherence or absorption, or other osteoporosis risk factors.
SER, Spanish Society of Rheumatology; KSBMR/KCR, Korean Society for Bone and Mineral Research/Korean College of Rheumatology; ACR, American College of Rheumatology; NOGG, National Osteoporosis Guideline Group; SIOMMMS, Società Italiana dell’Osteoporosi del Metabolismo Minerale e delle Malattie dello Scheletro; SEIOMM, Sociedad Española de Investigación Ósea y Metabolismo Mineral; SFR/GRIO, French Society for Rheumatology and Osteoporosis Research and Information Group; JSBMR, Japanese Society for Bone and Mineral Research; IOF-ECTS, International Osteoporosis Foundation and the European Calcified Tissue Society; SBR/BMA/ABMFR, Brazilian Society of Rheumatology/Brazilian Medical Association/Brazilian Association of Physical Medicine and Rehabilitation; DVO, Dachverband Osteologie e. V.; BBC, Belgium Bone Club; RCP, Royal College of Physicians; NA, not available; OP, osteoporosis; FRAX, fracture risk assessment tool; BMD, bone mineral density; GC, glucocorticoid; VFA, Vertebral Fracture Assessment.