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.