Steroid bisphosphonate guidelines

Despite the use of CTX for predictive purposes, a growing number of dissenting authors have questioned and even refuted the value of CTX as a predictive biomarker for BRONJ. The limitations of CTX include interpatient variability, nonstandardized laboratory reference ranges, variation in terms of fasting or non-fasting sampling, and low interpretability of CTX values for oral and IV bisphosphonates. A review of the literature retained for this article yielded a number of studies advocating the use of CTX as a predictive test, whereas others concluded that CTX was not an adequate marker. Several authors minimized the value of CTX studies as an absolute indicator for risk assignment as outlined by Marx 6 but also proposed a more generalized “risk zone” categorization for patients with CTX values less than 150 pg/mL. 5,12

Several recent reports have described osteonecrosis of the jaws (ONJ) associated with the use of bisphosphonates. Osteonecrosis of the jaws is recognized as a serious complication of bisphosphonate therapy, more commonly with the intravenous form of the drugs. However, there is limited scientific understanding about the association between osteonecrosis of the jaws and bisphosphonates. Primary care physicians treating bone diseases with bisphosphonate need, therefore, to be aware of this potential risk and plan the prophylaxis, early diagnosis and prevention of potential consequences. In this article, I review the literature on this newly described complication, with particular focus on systemic and local predisposing pathologies, preventive measures suggested before and during therapy with oral bisphosphonates, and the frequent clinical presentation of the oral lesions. The expert panel recommendations for the management of care of patients who develop ONJ are summarized also.
ONJ has been linked with high-dose intravenous bisphosphonate use in patients with bony cancers and the observation has been extended at a much lower incidence to patients on oral bisphosphonates taken for osteoporosis. The benefit-risk ratio is still heavily weighted towards therapy but primary care physicians need to be aware of this link. The risk is greatest in those with poor oral health who are undergoing dental surgery. If there is doubt, then a review by an experienced oral surgeon is appropriate.

      Steroid therapy for polymyalgia rheumatica should make the patient feel better within days rather than weeks.

In large studies, women taking bisphosphonates for osteoporosis have had unusual fractures ("bisphosphonate fractures") in the femur (thigh bone) in the shaft ( diaphysis or sub-trochanteric region) of the bone, rather than at the femoral neck, which is the most common site of fracture. However, these unusual fractures are extremely rare (12 in 14,195 women) compared to the common hip fractures (272 in 14,195 women), and the overall reduction in hip fractures caused by bisphosphonate far outweighed the unusual shaft fractures. [32] There are concerns that long-term bisphosphonate use can result in over-suppression of bone turnover . It is hypothesized that micro-cracks in the bone are unable to heal and eventually unite and propagate, resulting in atypical fractures. Such fractures tend to heal poorly and often require some form of bone stimulation, for example bone grafting as a secondary procedure. This complication is not common, and the benefit of overall fracture reduction still holds. [32] [33] In cases where there is concern of such fractures occurring, teriparatide is potentially a good alternative because it does not cause as much damage as a bisphosphonate does by suppressing bone turnover. [34]

The efficacy of alendronic acid tablet 5 and 10 mg once daily in men and women receiving at least mg/day of prednisone (or equivalent) was demonstrated in two studies. At two years of treatment, spine BMD increased by % and % (relative to placebo) with alendronic acid tablet 5 and 10 mg/day respectively. Significant increases in BMD were also observed at the femoral neck, trochanter, and total body. In post-menopausal women not receiving oestrogen, greater increases in lumbar spine and trochanter BMD were seen in those receiving 10 mg alendronic acid tablet than those receiving 5 mg. Alendronic acid tablet was effective regardless of dose or duration of glucocorticoid use. Data pooled from three dosage groups (5 or 10 mg for two years or mg for one year followed by 10 mg for one year) showed a significant reduction in the incidence of patients with a new vertebral fracture at two years (Alendronic acid % vs. placebo %).

Steroid bisphosphonate guidelines

steroid bisphosphonate guidelines

In large studies, women taking bisphosphonates for osteoporosis have had unusual fractures ("bisphosphonate fractures") in the femur (thigh bone) in the shaft ( diaphysis or sub-trochanteric region) of the bone, rather than at the femoral neck, which is the most common site of fracture. However, these unusual fractures are extremely rare (12 in 14,195 women) compared to the common hip fractures (272 in 14,195 women), and the overall reduction in hip fractures caused by bisphosphonate far outweighed the unusual shaft fractures. [32] There are concerns that long-term bisphosphonate use can result in over-suppression of bone turnover . It is hypothesized that micro-cracks in the bone are unable to heal and eventually unite and propagate, resulting in atypical fractures. Such fractures tend to heal poorly and often require some form of bone stimulation, for example bone grafting as a secondary procedure. This complication is not common, and the benefit of overall fracture reduction still holds. [32] [33] In cases where there is concern of such fractures occurring, teriparatide is potentially a good alternative because it does not cause as much damage as a bisphosphonate does by suppressing bone turnover. [34]

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