Saturday, November 27, 2010

Clinical Snippets: Steroid Induced osteoporosis(SIOP)

When should you be cautious regarding the possibility of SIOP?
  • Patients receiving at least 30mg of hydrocortisone or 7.5mg of prednisolone for a period of at least 3 months are at risk for SIOP. Steroid replacement in corticosteroids deficiency states compared to immunosuppresive therapy has lesser risk for SIOP.
Site of SIOP fracture?
  • Axial skeleton (Lumbar vertebrae is the first site) 
  • Proximal femur
How does SIOP occur?
  • Increase in osteoclastic activity
  • Decrease in osteoblastic activity
  • Calciuresis
  • Decreased intestinal absorption of calcium
  • Decrease in gonadal hormones esp. estrogens

Who are at risk?
  • Postmenopausal females
  • Higher dose of steroids for longer duration
  • Immobilised
  • Mal absorption and nutritionally compromised
  • On drugs as frusemide
  • Poor sun exposure
  • Coexistent renal disease
Does the steroid type determine incidence of SIOP?
  • Prednisolone followed by dexamethasone are the champs.
What should you do?
  •  Use steroids for the right indication, at the lowest required dose, for the shortest possible time.
  • Try to include steroid sparing drugs the earliest in connective tissue disorders (eg Azathioprine).
  • Change the concomitant drugs eg thiazide instead of frusemide.
Treatment ?
  • Stop or reduce steroids.
  • Alternate route of administration eg inhalation and local injection.
  • Calcium at least 1000mg per day and Vit. D3 0.25-1 mcg per day
  • Bisphosphonates eg Alendronate 70mg once weekly or 5-10mg per day PO.
  • Calcitonin nasal sprays.
  • Physiotherapy (skeletal loading).
  • Gonadal hormone replacement therapy (beware of CAD risk).

What if fracture occurs ?
  • Work in association with your orthopaedic colleague.