Initiate Prevention of Steroid-Induced Bone Loss in SLE Early

BIRMINGHAM, ENGLAND — All patients with systemic lupus erythematosus who are taking 7.5 mg prednisone or more daily should be treated to prevent bone loss, Bevra Hahn, M.D., said at the joint meeting of the British Society for Rheumatology and the German Society for Rheumatology.

Almost everyone loses bone mass at that level of steroid treatment, and relatively rapidly. “We know most bone loss occurs in the first 12 months of steroid treatment, so there isn't any point … waiting until the disease goes into remission—and lupus hardly ever goes into true remission—or waiting until they are better or their drug regimen is simpler,” she said.

Despite the fact that estrogen therapy is “out,” there are still treatment options. Calcium plus vitamin D supplementation is a typical initial approach, and has a small but measurable impact on reducing the degree of bone loss.

Another choice would be to use a vitamin D metabolite such as calcitriol. “These are more effective, but if you use a vitamin D metabolite, don't give supplemental calcium and be sure to monitor for hypercalcemia and maybe even hypercalcuria if you are practicing in an area where there are a lot of renal stones,” said Dr. Hahn, professor of medicine and chief of rheumatology, University of California, Los Angeles. Hypercalcemia is particularly hazardous when patients are acutely ill and take to bed. The drug should be stopped at that time, she said.

But there's no question in 2005 that bisphosphonate therapy is the most effective strategy to prevent bone loss in steroid-induced osteoporosis, she said. In fact, calcium plus ordinary vitamin D has been used as the placebo in a lot of the clinical trials of bisphosphonates.

“It doesn't matter which one you choose—whichever one you like. Now that Fosamax comes in a liquid I have a lot more patients who can tolerate bisphosphonate therapy,” she said. Liquid alendronate causes less esophageal irritation and gastric distress than the capsules, she said.

Another option for certain patients is treatment with the anabolic hormone PTH 1–34 (teriparatide, Forteo). This drug is useful for patients who have very low bone turnover and are continuing to fracture despite treatment with bisphosphonates, active vitamin D, and calcitonin, she said.

In some patients it isn't enough to turn the osteoclast off, which is how these drugs work. For these patients it's also necessary to turn the osteoblast on, which is what PTH does, she said.

PTH stimulates osteoblast accumulation and bone formation through receptor signals that modulate osteoblast proliferation and maturation. It also increases the lifespan and productivity of the osteoblast by preventing apoptosis (Treat. Endocrinol. 2002:1;175–90).

Unfortunately, patients don't like to take this drug because it's injectable and must be taken every day or every other day. But three other formulations, two injectable and one oral, are now in clinical trials (Expert Opin. Investig. Drugs 2005;14:251–64).

One caution is needed with using PTH in patients with lupus. “This is not recommended by anybody but me, but I think you should screen your patients for hyperparathyroidism before you start PTH. I have found elevated levels of parathyroid hormone in one-third of my lupus patients, and we shouldn't be giving PTH to people who already have primary hyperparathyroidism,” she said.

BIRMINGHAM, ENGLAND — All patients with systemic lupus erythematosus who are taking 7.5 mg prednisone or more daily should be treated to prevent bone loss, Bevra Hahn, M.D., said at the joint meeting of the British Society for Rheumatology and the German Society for Rheumatology.

Almost everyone loses bone mass at that level of steroid treatment, and relatively rapidly. “We know most bone loss occurs in the first 12 months of steroid treatment, so there isn't any point … waiting until the disease goes into remission—and lupus hardly ever goes into true remission—or waiting until they are better or their drug regimen is simpler,” she said.

Despite the fact that estrogen therapy is “out,” there are still treatment options. Calcium plus vitamin D supplementation is a typical initial approach, and has a small but measurable impact on reducing the degree of bone loss.

Another choice would be to use a vitamin D metabolite such as calcitriol. “These are more effective, but if you use a vitamin D metabolite, don't give supplemental calcium and be sure to monitor for hypercalcemia and maybe even hypercalcuria if you are practicing in an area where there are a lot of renal stones,” said Dr. Hahn, professor of medicine and chief of rheumatology, University of California, Los Angeles. Hypercalcemia is particularly hazardous when patients are acutely ill and take to bed. The drug should be stopped at that time, she said.

But there's no question in 2005 that bisphosphonate therapy is the most effective strategy to prevent bone loss in steroid-induced osteoporosis, she said. In fact, calcium plus ordinary vitamin D has been used as the placebo in a lot of the clinical trials of bisphosphonates.

“It doesn't matter which one you choose—whichever one you like. Now that Fosamax comes in a liquid I have a lot more patients who can tolerate bisphosphonate therapy,” she said. Liquid alendronate causes less esophageal irritation and gastric distress than the capsules, she said.

Another option for certain patients is treatment with the anabolic hormone PTH 1–34 (teriparatide, Forteo). This drug is useful for patients who have very low bone turnover and are continuing to fracture despite treatment with bisphosphonates, active vitamin D, and calcitonin, she said.

In some patients it isn't enough to turn the osteoclast off, which is how these drugs work. For these patients it's also necessary to turn the osteoblast on, which is what PTH does, she said.

PTH stimulates osteoblast accumulation and bone formation through receptor signals that modulate osteoblast proliferation and maturation. It also increases the lifespan and productivity of the osteoblast by preventing apoptosis (Treat. Endocrinol. 2002:1;175–90).

Unfortunately, patients don't like to take this drug because it's injectable and must be taken every day or every other day. But three other formulations, two injectable and one oral, are now in clinical trials (Expert Opin. Investig. Drugs 2005;14:251–64).

One caution is needed with using PTH in patients with lupus. “This is not recommended by anybody but me, but I think you should screen your patients for hyperparathyroidism before you start PTH. I have found elevated levels of parathyroid hormone in one-third of my lupus patients, and we shouldn't be giving PTH to people who already have primary hyperparathyroidism,” she said.

BIRMINGHAM, ENGLAND — All patients with systemic lupus erythematosus who are taking 7.5 mg prednisone or more daily should be treated to prevent bone loss, Bevra Hahn, M.D., said at the joint meeting of the British Society for Rheumatology and the German Society for Rheumatology.

Almost everyone loses bone mass at that level of steroid treatment, and relatively rapidly. “We know most bone loss occurs in the first 12 months of steroid treatment, so there isn't any point … waiting until the disease goes into remission—and lupus hardly ever goes into true remission—or waiting until they are better or their drug regimen is simpler,” she said.

Despite the fact that estrogen therapy is “out,” there are still treatment options. Calcium plus vitamin D supplementation is a typical initial approach, and has a small but measurable impact on reducing the degree of bone loss.

Another choice would be to use a vitamin D metabolite such as calcitriol. “These are more effective, but if you use a vitamin D metabolite, don't give supplemental calcium and be sure to monitor for hypercalcemia and maybe even hypercalcuria if you are practicing in an area where there are a lot of renal stones,” said Dr. Hahn, professor of medicine and chief of rheumatology, University of California, Los Angeles. Hypercalcemia is particularly hazardous when patients are acutely ill and take to bed. The drug should be stopped at that time, she said.

But there's no question in 2005 that bisphosphonate therapy is the most effective strategy to prevent bone loss in steroid-induced osteoporosis, she said. In fact, calcium plus ordinary vitamin D has been used as the placebo in a lot of the clinical trials of bisphosphonates.

“It doesn't matter which one you choose—whichever one you like. Now that Fosamax comes in a liquid I have a lot more patients who can tolerate bisphosphonate therapy,” she said. Liquid alendronate causes less esophageal irritation and gastric distress than the capsules, she said.

Another option for certain patients is treatment with the anabolic hormone PTH 1–34 (teriparatide, Forteo). This drug is useful for patients who have very low bone turnover and are continuing to fracture despite treatment with bisphosphonates, active vitamin D, and calcitonin, she said.

In some patients it isn't enough to turn the osteoclast off, which is how these drugs work. For these patients it's also necessary to turn the osteoblast on, which is what PTH does, she said.

PTH stimulates osteoblast accumulation and bone formation through receptor signals that modulate osteoblast proliferation and maturation. It also increases the lifespan and productivity of the osteoblast by preventing apoptosis (Treat. Endocrinol. 2002:1;175–90).

Unfortunately, patients don't like to take this drug because it's injectable and must be taken every day or every other day. But three other formulations, two injectable and one oral, are now in clinical trials (Expert Opin. Investig. Drugs 2005;14:251–64).

One caution is needed with using PTH in patients with lupus. “This is not recommended by anybody but me, but I think you should screen your patients for hyperparathyroidism before you start PTH. I have found elevated levels of parathyroid hormone in one-third of my lupus patients, and we shouldn't be giving PTH to people who already have primary hyperparathyroidism,” she said.