Prevention and treatment of glucocorticoid-induced osteoporosis in adults: recommendations from the European Calcified Tissue Society

General measures for all patients prescribed glucocorticoid (GCs) for ≥3 months: normalize calcium and protein intake, attain 25(OH)D of 50-125 nmol/L, minimize fall risk

(R1-2) Preliminary fracture-risk assessment in patients likely to receive oral GCs for ≥3 months: women and men ≥ 50 years and patients at increased fracture risk

(R3-6) Assess fracture risk by history of fragility fracture, systematic vertebral imaging, GC dose-adjusted FRAX, bone mineral density (BMD) by DXA, fall risk and biochemical testing

(R7-12) Treat women and men ≥ 50 years with recent (<2 years) vertebral and/or non-vertebral fracture, and/or GC dosage ≥ 7.5 mg/day, and/or age ≥ 70 years, and/or T-score ≤ −1.5, and/or 10-year probability above country-specific GC dose-adjusted FRAX thresholds; refer premenopausal women and men < 50 years with Z-score ≤ −2 and/or fragility fracture to a bone specialist

(R13-18) In women and men ≥ 50 years: alendronate or risedronate first line at medium fracture risk; zoledronic acid or denosumab at high risk; teriparatide at very high risk; sequential therapy imperative after first-line denosumab or teriparatide

(R19-25) During treatment, regularly monitor clinical risk factors, systematic vertebral imaging, fall risk, BMD by DXA and biochemical testing