Most patients receiving prolonged oral corticosteroids for chronic skin diseases such as pemphigus vulgaris, dermatomyositis, and cutaneous lupus erythematosus are not receiving bisphosphonates to prevent the consequent glucocorticoid-induced osteoporosis that can accompany treatment, according to a small cross-sectional study in the January issue of the Archives of Dermatology.¹ The American College of Rheumatology (ACR) and the US Department of Veterans Affairs both have guidelines recommending the use of bisphosphonates with specific doses of glucocorticoids; however, no such guidelines exist for dermatologists.

Of 35 patients with chronic skin diseases treated with long-term glucocorticoids, 80% were not receiving bisphosphonates at the time they were referred to a tertiary center, the new study showed. On average, these patients began treatment with steroids 17 months prior to referral. Moreover, the study authors point out that the proportion of patients treated with bisphosphonates remained unchanged even after publication of the ACR guidelines.

"The low rate of bisphosphonate use prior to referral and prolonged time interval until initiation of prophylaxis are disappointing because bisphosphonates are agreed to be the most efficacious agents known to prevent glucocorticoid-induced osteoporosis (GIOP)," conclude the researchers, led by Rosemarie H. Liu, MD, a dermatologist at Eastern Virginia Medical School in Norfolk, Virginia. "This may be due to variations in knowledge about GIOP among different physician specialties," the investigators write.

However, they add, "unless there is a specific contraindication, bisphosphonates should be prescribed concomitantly with the initiation of corticosteroid therapy in diseases for which long-term glucocorticoid use is anticipated as part of the standard of care."

Dr. Liu and colleagues note that bone-mineral density (BMD) declines with a glucocorticoid dose as low as 5 mg/day, with reports of reductions in BMD at 2.5 mg/day.²

New treatment options and recommendations

In a related review article in the same issue of the journal,³ two dermatologists describe new treatment options and current recommendations among dermatologists for treating patients with systemic corticosteroids.

"Our profession uses high-dose systemic steroids commonly, mainly for autoimmune bulbous disease," says author Gil Yosipovitch, MD, associate professor in the department of dermatology, neurobiology and anatomy, and regenerative medicine at Wake Forest University Health Sciences in Winston-Salem, North Carolina. In fact, he says, dermatologists often use higher doses of steroids than other specialists.

"As [reported in the study by Liu et al], 80% of dermatologists' patients who required prolonged systemic steroid treatment did not receive any protective treatment for bone upon referral to a tertiary center," Dr. Yosipovitch says.

The importance of recommending bisphosphonate therapy is underscored by evidence that more than one-third of patients treated with corticosteroids for 5 to 10 years will suffer an osteoporotic fracture.⁴

Therefore, "the take-home message is straightforward and simple: Patients receiving high-dose (>5 mg/day) chronic (anticipated >3 months) prednisone should be started on 1500 mg/day of calcium and 800 IU/day of vitamin D and an oral bisphosphonate on the day they start therapy," he says.

 

References

1. Liu RH, Albrecht J, Werth VP. Cross-sectional study of bisphosphonate use in dermatology patients receiving long-term oral corticosteroid therapy. Arch Dermatol. 2006;142:37-41.
2. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res. 2000;15:993-1000.
3. Summey BT, Yosipovitch G. Glucocorticoid-induced bone loss in dermatologic patients. Arch Dermatol. 2006;142:82-90.
4. Baltzan MA, Suissa S, Bauer DC, Cummings SR. Hip fractures attributable to corticosteroid use. Lancet. 1999;353:1327.