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Glucocorticoids in rheumatic diseases: Is there a skeletal sparing dose?

Presented by
Dr Giovanni Adami, University of Verona, Italy
ACR 2022
Results of a cohort study that investigated changes in bone mineral density (BMD) on different regimens of glucocorticoids (GC) showed that even relatively low doses lead to significant bone loss in patients with inflammatory rheumatic musculoskeletal diseases (iRMD). Moreover, doses of 5 mg/day or higher doubled the fracture risk.

Prompted by a recent trial (NCT02585258) that found a 4% difference in BMD between placebo and prednisolone-treated elderly patients with rheumatoid arthritis, a new Italian study strove to find out more about dose-dependency and anti-osteoporotic treatment [1,2]. The longitudinal cohort study included 884 women with iRMD who were propensity score-matched to 1,766 healthy women by age, T-score, and 10-year fracture risk [1].

The cohort’s mean age ranged from 65 to 68, and over 85% were smokers. The median follow-up time was 2 years. The most frequent iRMD was rheumatoid arthritis (53.8%), and the mean T-scores of the femoral neck were -2.2 to -2.3. About 80% did not receive anti-osteoporotic therapy at baseline. In this subgroup of women, treatment with GC (noted in prednisone equivalent doses) entailed a significant seemingly dose-dependent BMD loss: -4.26% in those under prednisone ≥5 mg/day (P=0.0011), -4.23% in 2.5-5 mg/day (P=0.0422), and -2.66% in 0-2.5 mg/day (P=0.0006). Thus, interestingly, this reduction was not only present in patients with highly dosed GC. Dr Giovanni Adami (University of Verona, Italy), who presented the data, further stated that the women in the control group lost about 1.5% of BMD, which was to be expected in postmenopausal women. When patients on GC were treated with anti-osteoporotic medication, BMD was effectively increased only in the 2 groups on lower dosages of GC: from -4% to +3% (2.5-5 mg/day) and from -2.5% to +1% (0-2.5 mg/day). However, in the group with ≥ 5mg/day, the loss was only reduced by 1% from -4% to -3%.

Additionally, patients with iRMD and without anti-osteoporotic treatment had a higher fracture risk than the matched controls. In the latter, an incidence of 2.2 fractures/100 person-years (PY) was reported. For patients on 1 of the 2 lower dose regimens of GC, the risk was about 30% higher, with 2.5 fractures/100 PY and 2.8 fractures/100 PY. The risk of those on high-dose GC (≥5 mg/day) was about twice as high (4.8 fractures/100 PY) compared with the controls.

All in all, Dr Adami suggested that the bone-safe dose could be less than 5 mg/day and that a dose ≥5 mg might entail a higher risk than expected. “Should we prevent or treat glucocorticoid-induced osteoporosis even if a very low dose of glucocorticoids is used?” he asked in his conclusions.


    1. Adami G. Impact of glucocorticoid dosing and anti-osteoporotic treatment on bone health in patients with inflammatory rheumatic musculoskeletal diseases: a longitudinal cohort study. L01, ACR Convergence 2022, 10–14 November, Philadelphia, USA.
    2. Boers M, et al. Ann Rheum Dis. 2022;81:925-36.


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