The British Journal of Rheumatology, Vol 37, 292-299, Copyright © 1998 by British Society for Rheumatology
G Pearce, PF Ryan, PD Delmas, DA Tabensky and E Seeman
The beneficial effects of corticosteroid therapy in the treatment of
rheumatic diseases may be offset by the occurrence of corticosteroid-
related osteoporosis. This problem may be overcome by using low-dose
corticosteroids; however, the dose of corticosteroids that is both
efficacious and skeletal sparing is uncertain. Therefore, the aim of this
study was to determine whether low-dose prednisolone treatment results in
bone loss and modifies bone turnover. Nineteen patients (12 female, seven
male) suffering from polymyalgia rheumatica received 10 mg or less daily,
given in reducing dosage, with a range of 2.5-10 mg and an average of
6.0+/-0.2 mg daily (+/-S.E.M.). Prior to the commencement of therapy and at
regular intervals during treatment, bone mineral density (BMD) using dual
X-ray absorptiometry and circulating biochemical and hormonal determinants
of bone turnover were measured. The patients were followed for 14.4+/-1.6
months (range 6-27). They were compared to 19 age-matched controls. Despite
a mean exposure dose of 6 mg/day and disease remission, BMD decreased in
the patients at the lumbar spine (2.6+/-0.8%, P < 0.01), femoral neck
(2.9+/-1.5%, P=0.06), Ward's triangle (5.5+/-2.9%, P=0.06) and the
trochanter (4.3+/-1.9%, P < 0.05). Total body bone mass decreased by
50+/-19 g in the first 6 months (P < 0.02), and by 39+/-30 g in the
remaining 8 months of follow- up [not significant (NS)]. In the first 6
months, BMD decreased at the lumbar spine (1.7+/-0.9%, P = 0.06). From 6
months to the end of follow- up, BMD decreased by 8.5+/-3.5% at Ward's
triangle (P < 0.05) and by 4.8+/-2.5% at the femoral neck (P=0.08). The
fall in BMD correlated with the cumulative prednisolone dose at
trabecular-rich regions (trunk r=-0.72, P < 0.001; ribs r=-0.53, P <
0.05). Bone resorption, assessed by urinary cross-laps, was 54.7% higher
than controls before treatment was started (P < 0.05) and decreased by
23.5+/-7.1% in the first month of treatment when the mean prednisolone dose
was 9.1 mg/day, range 5-10 (P < 0.0001). Serum osteocalcin was not
suppressed by disease before treatment, decreased by 27.4+/-5.1% during the
first month of treatment (P < 0.001), remained suppressed while the
daily dose of prednisolone was > 5 mg/day, but returned to baseline
below this dose. Serum parathyroid hormone was 19.3% lower in the patients
than controls at baseline (NS), and increased by 46.1% (P < 0.05) but
was no higher than controls at any time. Muscle strength increased by
20-60% (P < 0.05 to < 0.01). Prophylaxis should be considered in
patients receiving > or = 5 mg/day prednisolone daily as bone loss is 2-
to 3-fold expected rates. Earlier trabecular bone loss may predispose to
spine and rib fracture; later cortical bone loss may predispose to hip
fractures. Doses of prednisolone of < 5 mg daily may be skeletal
sparing, but may not be efficacious.
ORIGINAL PAPERS
The deleterious effects of low-dose corticosteroids on bone density in patients with polymyalgia rheumatica
Austin and Repatriation Medical Centre, Heidelberg, Victoria, Australia.
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