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218 Letters to the Editor / Clinical Neurology and Neurosurgery 109 (2007) 216–219

Corticosteroid-induced osteoporosis in neurology patients

Keywords: Osteoporosis; Prevention; Glucocorticoids; Bisphosphonates; Myasthenia gravis; Neurology

Dear Editor,

In their audit Lozsadi et al. [1] give an important reminder

of the morbidity of iatrogenic osteoporosis and guidelines including suboptimal lifestyle risk factor identification but
designed to prevent it. However, inaccessibility of dual- also apparent confusion as to the circumstances when DEXA
energy X-ray absorptiometry (DEXA) scanning, at their scans should be used and when bisphosphonates are rec-
centre, makes comparison of the bone protective measures ommended. We have audited strictly according to the UK
instigated and the national guidelines [2] difficult. Royal national guidelines, however in our group corticosteroids
College of Physicians’ guidelines recommend treatment in were prescribed for a mean of 8.2 years often at high doses
all patients aged over 65 years or those with a history of (mean 28.2 mg), and therefore it would seem remiss to with-
previous fragility fracture irrespective of T-score on DEXA hold osteoprotective therapy until T-score is <−1.5 and irre-
bone density scan. Explicit subclass analysis based on age is versible damage is done. Previous guidelines [3] had a daily
not given but we calculate as follows. In over 65 year olds, dose threshold of 15 mg for treatment irrespective of T-score.
bone protection was used in 20/25 (80%) at pre-intervention, This applies to 15/18 (83%) of our patients and in view of
19/26 (73%) post-intervention in 2001 and 20/21 (95%) post- the typical chronicity of treatment, we suggest that patients
intervention in 2003. Therefore, in the one group with a clear may benefit from reinstating a dose threshold to the national
indication according to the guidelines, results were impres- guidelines. Indeed, the American College of Rheumatology
sive even before intervention. In the under 65 year subgroup, [4] go further; any patient initiating treatment of >5 mg pred-
bone protection was used in 9/23 (39%) pre-intervention, nisolone for >3 months should start a bisphosphonate. For
19/22 (86%) post-intervention in 2001 and 24/27 (89%) those on long-term steroids, the cut-off for T-score is <−1.0
post-intervention in 2003. This subgroup is responsible for (compared to <−1.5 in UK), and all patients with T-score
the majority of the total increase. However, it is this group >−1.0 should have repeat DEXA annually or biannually
that provides the greatest difficulty and the ultimate deci- (compared to three yearly in UK). Also, in the RCP guidelines
sion on which bone protecting agent to use depends pri- there is no proviso for patients with T-score >0 as to when
marily on risk stratification with bone densiometry scans. repeat DEXA scan is required. Addition of a dose threshold
The implied target of 100% bone protective agent use in the to the UK guidelines may simplify the treatment algorithm
<65 year old group (particularly bisphosphonates) may rep- and have the advantage of reducing the need for bone den-
resent over-treatment using strict adherence to the national siometry measurements, particularly where repeat scanning
guidelines. at 1–3 year intervals is advocated or where local availability is
We provide complementary data from of our retrospec- limited. This appears justified considering the relatively low
tive case-notes audit on corticosteroid treated myasthenia complication rate with bisphosphonates. Indeed, the Lozsadi
gravis patients (the diagnosis in 84% at pre-intervention group were perhaps not incorrect to consider osteoprotection
in the Lozsadi paper). 7/18 (39%) had no reduction in for all patients provided appropriate counselling and moni-
steroid maintenance dose since diagnosis, steroid-sparing toring of bisphosphonate side-effects is done.
agent was not considered in 2/18 (11%) and general risk
factors for osteoporosis were poorly considered; dietary his-
tory 5/18 (28%), exercise and weight-bearing advice 5/18 References
(28%), smoking and alcohol history 13/18 (72%). In the
[1] Lozsadi DA, Peters G, Sadik HY, Kellett MW, Fox SH, Smith DF. Preven-
>65 year old group 4/6 (67%) had not started a bisphospho- tion of osteoporosis in glucocorticoid-treated neurology patients. Clin
nate, including one who had taken prednisolone for >3 years Neurol Neurosurg 2006;108:157–62.
and one for >10 years. In the <65 year old group, DEXA [2] Bone and Tooth Society, National Osteoporosis Society, Royal College
scanning was requested in only 5/12 (42%) and there was of Physicians. Glucocorticoid-induced osteoporosis: guidelines for pre-
vention and treatment. London: RCP; 2002.
general confusion as how to interpret the T-value of these
[3] National Osteoporosis Society. Guidance on the prevention and manage-
scans. This included under-treatment (no bisphosphonate for ment of corticosteroid induced osteoporosis. Bath: National Osteoporo-
patients with T-score <−1.5) and over-treatment (when T- sis Society; 1998.
score >0). [4] American College of Rheumatology. Recommendations for prevention
There appears to be a lack of awareness and non- and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheum
implementation of the national guidelines by neurologists,
Letters to the Editor / Clinical Neurology and Neurosurgery 109 (2007) 216–219 219

∗ Corresponding
David A. Gallagher ∗ author. Tel.: +44 2085235185.
Aaron Sturrock E-mail address: damg (D.A. Gallagher)
Barts & The London NHS Trust,
5 June 2006
Department of Neurology, Royal London Hospital,
Whitechapel Road, London E1 1BB, United Kingdom doi: 10.1016/j.clineuro.2006.07.005