Case 106 – Summary

Thank you all for your contributions this week.

 

We focused on a patient with a new diagnosis of primary immune thrombocytopenia (ITP), please refer to TeamHaem case 11 for a full summary of this condition.

 

In the wake of a new BSH good practice guideline, our goal this week was to evaluate our patient’s risk of developing glucocorticoid-induced osteoporosis following initiation of first line ITP management with steroids. How many of us have started steroid therapy for a patient without considering the impact their treatment may have on their bone health?

 

Background

Fragility fractures occur in up to half of all patients receiving long-term steroids, vertebral fractures are the most common. This is a major source of preventable morbidity and disability.

Steroids directly inhibit bone formation by triggering osteoblast apoptosis and blocking normal osteoblast activity. Indirectly, steroids also reduce bone mineral density by inhibiting calcium absorption from the gut.

Changes in bone mineral density and the increased risk of fragility fractures occur quickly after the onset of steroid use (within first 3-6 months). Therefore, osteoporosis risk assessment must occur at the time of treatment initiation.

For all adult patients commencing glucocorticoids:

  • Give lifestyle advice to reduce risk factors associated with fragility fractures
    • Weight-bearing exercise, smoking cessation, decrease alcohol intake
  • Check serum calcium and vitamin D levels
  • Adequate daily vitamin D (800 iu) and calcium (7001200 mg) intake in adults is recommended, consider oral supplementation 

Initial fracture risk assessment

  • Patients at high risk of fracture should be considered for oral alendronate or risedronate
  • Everyone aged ≥70 years, can be considered high risk and treatment should be considered without the requirement for further assessment 
  • Men aged ≥50 years and post‐menopausal women with a previous fragility fracture can also be considered high risk and treatment should be considered without the requirement for further assessment
  • Everyone else >40 years old should be assessed by FRAX score without bone mineral density (BMD) assessment at treatment onset ( www.sheffield.ac.uk/FRAX/tool.jsp) to define risk 
  • Intermediate risk should have a dual energy x‐ray absorptiometry (DXA) scan and femoral neck BMD entered into FRAX® to define high and low risk. However, a decision can be made clinically in patients where a DXA results is unlikely to be available in a timely manner).
  • Adults aged <40 years and children do not routinely require assessment.

Patients receiving similar glucocorticoid regimens for relapse 

  • Is there a steroid sparing alternative?
  • If the patient has previously had bone protection, restart it
  • If re-treated within a year consider men aged ≥50 years and post‐menopausal women high risk and treat with bone protection
  • Other adults aged ≥40 years should undergo fracture risk assessment 

Bisphosphonates

Contraindicated

·        Hypocalcaemia

·        Hypersensitivity

·        Severe renal impairment

·        Pregnancy

·        Lactation

Avoid

·        In patients who are unable to sit/stand for 30 – 60 minutes

·        Oesophageal stricture

·        Achalasia

Considerations

·        Risk of osteonecrosis

·        Dental health

Main learning points when commencing steroids for in a patient with new ITP:

  1. Adults should receive lifestyle advice (regular weight‐bearing exercise, stop smoking, reduce alcohol intake to ≤2 units/day).
  1. Adults should receive adequate daily intake of calcium (700–1200 mg) and vitamin D (800 IU) through diet if possible or supplements if needed
  1. Bone loss and increased fracture risk occur early after initiation of glucocorticoids, bone‐protective treatment should therefore be started at the onset of therapy in patients at increased risk of fracture.

References:

Hill, Q. A., Grainger, J. D., Thachil, J. , Provan, D. , Evans, G. , Garg, M. , Bradbury, C. , Bagot, C. , Kanis, J. A., Compston, J. E. and , (2019), The prevention of glucocorticoid‐induced osteoporosis in patients with immune thrombocytopenia receiving steroids: a British Society for Haematology Good Practice Paper. Br J Haematol. doi:10.1111/bjh.15735

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