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Use of strong topical corticosteroids tied to osteoporosis, fracture risk

JAMA Dermatology
Reuters Health - 04/02/2021 - Use of potent or very potent topical corticosteroids (TCSs) is associated with increased risk of osteoporosis and major osteoporotic fractures, with a dose-dependent effect, according to a large cohort study by researchers in Denmark.

"Based on these findings, clinicians may need to consider other corticosteroid-sparing therapeutic options for people requiring potent anti-inflammatory treatment on large body surfaces for prolonged periods to limit the risk of osteoporosis," they write in JAMA Dermatology.

Still, although the population-attributable risk may be as high as 4.3%, "the absolute risk to the average TCS user was low," the team notes.

"The take-home message is that, when used responsibly and in limited amounts, TCSs are generally safe. However, there is a proportion of patients with extensive or persistent disease activity who may require prolonged therapy," lead author Dr. Alexander Egeberg of the University of Copenhagen added in an email to Reuters Health.

It's well established that systemic corticosteroids increase the risk of osteoporosis and related fractures. Whether topical use of strong steroids, as recommended for psoriasis and atopic dermatitis for instance, can cause similar problems is not clear.

The researchers identified all Danish residents ages 18 and older who had filled prescriptions from 2003 through 2017 for at least 200g of mometasone furoate (1mg/g), or the equivalent amount of other potent or very potent TCSs, including betamethasone 17 valerate and clobetasol propionate.

The mean age of the more than 723,000 individuals in the cohort was 52, and 53% were women.

After adjusting for age, sex, socioeconomic status, medication use and comorbidities, the researchers found significant associations between use of potent or very potent TCSs and osteoporosis, beginning with exposures of at least 500g and becoming increasingly stronger with higher cumulative use.

Similarly, TCS use was associated with increasing risk of major osteoporotic fracture, starting with cumulative doses of at least 1000g.

Overall, a 3% increase in relative risk of osteoporosis and major osteoporotic fracture was seen for every doubling of the TCS cumulative does (hazard ratio, 1.03; 95% confidence interval, 1.02 to 1.04 for both).

Dr. Egeberg said that in patients who require prolonged topical steroid therapy, clinicians may want to switch to another treatment alternative, if possible.

"Alternatively, if other alternatives are not possible, we may want to consider doing a DXA scan or recommend oral prophylactic therapy with calcium and vitamin D," he added.

In an accompanying editorial, Dr. Rebecca D. Jackson of the Center for Clinical and Translational Science at Ohio State University, in Columbus, noted that the study's findings do not indicate that the usual TCS doses prescribed for most dermatologic conditions are problematic.

"For conventional, lower cumulative doses, the strength of the evidence of risk does not support a need to extensively change current treatment practices," she writes.

Dr. Adam Goldstein, a professor of family medicine at the University of North Carolina at Chapel Hill, called the study's findings "concerning." Dr. Goldstein, who was not involved in the new research, is a co-author of the textbook Practical Dermatology.

"This study shows what most physicians already intuitively know, there is no free ride when treating complex and serious diseases like psoriasis," he told Reuters Health by email. "Potent topical steroids are still a critical part of the treatment paradigm for many dermatologic diseases, but as with any medication, we should strive for the lowest effective dose for shorter periods of time if possible and choose safer medications if available."

Dr. Beth Wallace of the division of rheumatology at Michigan Medicine, in Ann Arbor, told Reuters Health by email, "Since topical steroids are used very commonly, even these very small risks are important on a population level."

"Medication-related risks can certainly be outweighed by major treatment benefits," added Dr. Wallace, who also was not involved in the study. "For example, long-term use of high-dose topical steroids may be appropriate for certain patients with serious, chronic skin conditions, like psoriasis or severe eczema."

Dr. Wallace noted that the authors did not report the indications for topical steroid use in this population. "It would be interesting to know what proportion of these strong steroids was prescribed for short-term or self-limited conditions, as prior studies suggest is often the case for oral steroid bursts."

SOURCE: https://bit.ly/3oMMvDd and https://bit.ly/3rnmT1k JAMA Dermatology, online January 20, 2021.

By Scott Baltic

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