Orlando who has been taking steroids for rheumatoid arthritis over several years presents with a compression vertebral fracture. This fracture is due to:
A. An entirely separate condition.
B. The osteoporotic effect of long-term steroid use.
C. Deterioration in rheumatoid arthritis.
D. An excessively high dose of steroids.
Correct Answer: B. The osteoporotic effect of long-term steroid use.
In a client on long-term steroids, a compression vertebral fracture can be assumed to be due to the steroids’ bone-softening effect. Corticosteroids impair the mineralization of bone matrix by initially favoring the activity of osteoclasts (during the first 6 to 12 months of therapy) while also inhibiting the absorption of calcium in the gut. Corticosteroids have also been shown to cause a decrease in bone formation by reducing the activity and lifespan of osteoblasts, promoting their apoptosis as well as the apoptosis of osteocytes.
Option A: Research has shown that prednisone doses as low as 5 mg/day can lead to bone loss. The use of 5 mg or more per day of prednisolone (or its equivalent) has been associated with significant reductions in bone mineral density (BMD) and increased fracture risk within 3 to 6 months of initiation.
Option C: Researchers saw osteonecrosis in a study in 9 to 40% of patients receiving long-term corticosteroid therapy, both systemic and intra-articular routes, as well as in the absence of corticosteroid-induced osteoporosis. Alcoholism, sickle cell disease, human immunodeficiency virus (HIV) infection, and radiation exposure are also associated with osteonecrosis.
Option D: Clinicians should consider bone mineral density (BMD) testing at baseline and after one year of corticosteroid therapy along with height measurement and screening for any fragility fractures. Subsequent assessments can then be pushed out to every 2 to 3 years if stable at one year.[2] If the patient shows decreased BMD, consider pharmacologic therapy, and the recommendation is to use that the World Health Organization’s Fracture Risk Assessment Tool (FRAX) to determine patients who will benefit from pharmacologic treatment.