Treatment of Special Populations

Premenopausal Women

The NOF recommends measuring bone mineral density in premenopausal women with specific risk factors for osteoporosis, such as medical condition or medication, in whom treatment would be considered.1 Premenopausal women at risk for osteoporosis should follow all nonpharmacologic recommendations for exercise and adequate calcium and vitamin D intake. Currently, no good data are available regarding pharmacologic therapy on fracture reduction in this population. Bisphosphonates should be used with caution in this population due to pregnancy risks and uncertain long-term effects.

Compared to postmenopausal osteoporosis, few clinical trials have been conducted evaluating therapies in men. Although alendronate and calcitonin have both been studied, only alendronate reduces fracture rates in men. Teriparatide has also been studied, but no data are yet available on fracture rates. At this time, alendronate and teriparatide are FDA-approved for the treatment of osteoporosis in men. Dae to proven benefit in reducing fractures and relative safety, alendronate should be considered first-line treatment for primary osteoporosis in men. Teriparatide should be reserved as alternate therapy in this population. Because secondary osteoporosis causes play a significant role in men, any secondary cause (e.g., hypogonadism) should be excluded or treated before considering other drug therapy.

Glucocorticoid-Induced Osteoporosis

Glucocorticoids play a significant role in bone remodeling. Exogenous glucocorticoid administration results in an increase in bone resorption, inhibition of bone formation, and change in bone quality. Glucocorticoids (e.g., prednisone, hydrocortisone, methyl-prednisolone, and dexamethasone) promote bone resorption through reduced calcium absorption from the GI tract and increased renal calcium excretion. Bone formation is reduced through inhibition of osteoblasts. They also decrease estrogen and testosterone production.

Patients receiving long-term glucocorticoids are at increased risk of fracture. This risk is greater with higher doses and longer-term therapy. Most bone is lost during the initial 6 to 12 months of therapy, and bone mass continues to decline thereafter. Due to the risk of bone loss and fractures, therapy is recommended for patients receiving long-term supraphysiologic doses of glucocorticoids.

In addition to nonpharmacologic measures, the American College of Rheumatology (ACR) has specific recommendations for preventing and treating patients receiving glucocorticoids.43 Recommendations for optimal calcium and vitamin D intake are higher for patients receiving glucocorticoids. These recommendations include 1,500 mg daily of elemental calcium and 800IU daily of vitamin D for all adults receiving glucocorticoids. Patients should take a vitamin D-containing supplement to ensure these requirements are being met.

The ACR recommends bisphosphonate therapy for all patients who are starting treatment with glucocorticoids (prednisone 5 mg or more daily or equivalent) that will continue for 3 months or longer. For patients receiving chronic glucocorticoids (prednisone 5 mg or more daily or equivalent), bisphosphonate therapy is also recommended if the bone mineral density is low or there is a history offracture43 Calcitonin may be used in patients who are intolerant of bisphosphonates.

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