Treatment with Glucocorticoids and Fragility Fractures

Glucocorticoids, taken chronically at certain dosages (5mg/day of prednisone >3 months), interfere with bone metabolism (both the quality and quantity), making bone more fragile and increasing the risk of fractures. The osteopenic effect is most rapid during the first 6–12 months of treatment, especially at the level of the trabecular bone. The literature shows that patients chronically treated with glucocorticoids, at a minimum dose of 5 mg/day for more than 1 year, have a high risk of fragility fractures and that at least 30–50% of them sustain at least one osteoporotic fracture (vertebral body, ribs, femur). Glucocorticoids are strong inhibitors of new bone formation, an effect mediated by direct inhibition of the activity and replication of osteoblasts; at the same time, they inhibit osteoclast apoptosis and thus increase bone resorption. The aim of our study was to evaluate the frequency of use of oral glucocorticoids in a sample of subjects with hip fracture, compared with an age-matched sample of fracture-free subjects.Materials and methods: As part of an epidemiological survey (Indaco 2 study), proposed by SIOT (the Italian Society of Orthopaedics and Traumatology), 7355 patients attending over 100 orthopaedics and traumatology clinics throughout Italy were recruited over a 6-month period. At each centre 30 patients with a femoral fracture and 30 fracture-free patients aged over 65 years were recruited. These patients were administered a questionnaire that investigated their reason for attending the clinic, various aspects of their history (walking capacity by means of the FAC scale), cognitive status, and presence/absence of chronic treatment with oral glucocorticoids.Results: Of the 7355 questionnaires processed, 954 (12.97%) were excluded, because they referred to patients aged under 65 years or because of missing data (failure to indicate the presence/absence of treatment with glucocorticoids). Therefore, the number of questionnaires actually assessed was 6401 (87% of the recruited subjects), 2875 (44.9%) from fracture patients and 3526 (55%) from fracture-free subjects. Of the 592 (9.2%) patients found to be under chronic treatment with glucocorticoids, 11 were excluded because gender was not indicated. The population whose data we process thus comprised 581 patients: 93 males and 488 females. Of the 93 males (16%), 33 (35.5%) had fractures and 60 (64.5%) did not. Of the 488 females (84%), 185 (38%) had femoral fractures and 303 (62%) were fracture-free.Discussion and conclusions: In the population we assessed it was found that chronic treatment with prednisone or equivalent drugs at a dose of at least 5 mg/day for more than 3 months does not further increase the risk of proximal femur fracture. Presumably, this finding depends on the very advanced mean age of the subjects examined, which probably created a “ceiling effect” for the FRAX algorithm.