Summary

ACR 2017 update on prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) in adults and children on prednisone ≥2.5 mg/day for ≥3 months. Uses GRADE methodology and FRAX-based (GC-adjusted) fracture risk stratification to guide therapy, with oral bisphosphonates as preferred first-line agents in most moderate-to-high risk patients. Addresses special populations including children, organ transplant recipients, women of childbearing potential, and patients on very high-dose GCs.

Key Recommendations

Perform initial clinical fracture risk assessment with FRAX (GC-adjusted) and BMD in adults ≥40 years within 6 months of starting long-term GC therapy.
All patients on prednisone ≥2.5 mg/day for ≥3 months should optimize calcium and vitamin D intake plus lifestyle modifications (exercise, smoking cessation, limit alcohol).
Adults ≥40 at low fracture risk: calcium and vitamin D alone (no bisphosphonates, teriparatide, denosumab, or raloxifene).
Adults ≥40 at moderate or high fracture risk: treat with an oral bisphosphonate as first-line (strong recommendation for high risk).
If oral bisphosphonate not appropriate, use IV bisphosphonate, then teriparatide, then denosumab; raloxifene only in postmenopausal women when no other agent is appropriate.
Avoid denosumab in organ transplant recipients due to lack of safety data with concurrent immunosuppression.
Adults <40 with prior osteoporotic fracture or continuing GC ≥7.5 mg/day for ≥6 months with Z-score <-3 or rapid bone loss (>10%/year): treat with oral bisphosphonate.
Reassess fracture risk every 12 months clinically; repeat BMD every 1–3 years in adults ≥40 not on OP medication (every 2–3 years in adults <40 on treatment).
For treatment failure (fracture after ≥18 months on oral bisphosphonate or BMD loss ≥10%/year): switch to teriparatide, denosumab, or IV bisphosphonate.
After completing 5 years of oral bisphosphonate in moderate-to-high risk patients still on GCs: continue or switch active therapy rather than stop.
Children 4–17 on GCs ≥3 months: optimize calcium (1,000 mg/day) and vitamin D (600 IU/day); add oral bisphosphonate if osteoporotic fracture occurs and GC dose ≥0.1 mg/kg/day continues.
In women of childbearing potential at moderate-to-high risk not planning pregnancy: oral bisphosphonate preferred, then teriparatide; reserve IV bisphosphonates and denosumab for high-risk only.

Thresholds & Doses

Guideline applies to prednisone ≥2.5 mg/day for ≥3 months.
Calcium intake target: 1,000–1,200 mg/day.
Vitamin D intake target: 600–800 IU/day; serum 25(OH)D ≥20 ng/mL.
Alcohol limit: 1–2 drinks/day (≥3 units/day is a risk factor).
FRAX GC adjustment if prednisone >7.5 mg/day: multiply major OP fracture risk by 1.15 and hip fracture risk by 1.2.
High fracture risk (≥40 years): prior OP fracture, T-score ≤-2.5 (men ≥50/postmenopausal women), FRAX 10-yr major OP fracture ≥20%, or hip fracture ≥3%.
Moderate fracture risk (≥40 years): FRAX 10-yr major OP fracture 10–19% or hip fracture >1% and <3%.
Low fracture risk (≥40 years): FRAX 10-yr major OP fracture <10% and hip fracture ≤1%.
Moderate-to-high risk (<40 years): prior OP fracture, Z-score <-3, bone loss >10%/year, or very high-dose GCs.
Very high-dose GC definition: prednisone ≥30 mg/day with cumulative dose ≥0.5 gm (or >5 gm) in 1 year.
BMD reassessment interval: every 1–3 years in adults ≥40 on GCs without OP medication; every 2–3 years in adults <40 with risk factors.
Treatment failure threshold: fracture after ≥18 months of oral bisphosphonate or BMD loss ≥10%/year.
Oral bisphosphonate duration before reassessment for continuation/switch: 5 years.
Pediatric GC threshold for bisphosphonate after fracture: ≥0.1 mg/kg/day for ≥3 months.
Organ transplant recommendations apply if GFR ≥30 mL/min and no metabolic bone disease.

Citations

Table 1 — Fracture risk categories (high/moderate/low) in GC-treated adults by age.
Figure 1 — Initial fracture risk assessment algorithm within 6 months of GC start.
Figure 2 — Annual clinical fracture risk reassessment and BMD intervals.
Figure 3 — Initial pharmacologic treatment algorithm for adults.
Table 2 — Initial treatment recommendations by age and risk stratum (oral bisphosphonate preferred first-line).
Table 3 — Recommendations for special populations: women of childbearing potential, very high-dose GCs, organ transplant, children 4–17.
Table 4 — Follow-up treatment recommendations (treatment failure, completion of 5-year bisphosphonate course, GC discontinuation).
Recommendations section — Calcium 1,000–1,200 mg/day and vitamin D 600–800 IU/day for all GC-treated patients.