The reason for this letter is a number of comments related to the article on treatment thresholds in patients over 50 years of age by Brance et al., published in CLINICAL RHEUMATOLOGY in October 2022, which demonstrated multiple misconceptions regarding glucocorticoid-induced osteoporosis.
In our opinion, the most important of these are as follows:
- 1
It is totally incorrect to set a threshold for treatment intervention based almost exclusively upon an arbitrary densitometric value, since glucocorticoids produce changes in bone structure in three dimensions, which cannot be measured with DXA as it is a planar method.
For this reason, at the same T-score value, the fracture rate in patients with corticoid-induced osteoporosis is twice that of patients with primary osteoporosis. Consequently, there are fractured patients with higher and even normal bone mineral density values vs. patients with primary osteoporosis. For this reason, basing treatment thresholds on bone mineral density values is a serious error which, in addition, shows ignorance of the biomechanical effects of corticosteroids on bone.
- 2
It is absolutely mandatory to incorporate FRAX, depending on the dose of corticosteroids used, since many other factors influence the risk of fracture.
- 3
It is necessary to divide patients into those over and under 40 years of age. Patients under 40 years of age, for whom T-score values should not be used, cannot be disregarded.
- 4
No modern clinical practice guidelines consider almost exclusively, as this article does, the T-score value (ACR 2017 guidelines updated in 2022, Latin American clinical practice guidelines from the International Osteoporosis Foundation [IOF] 2022 and the Brazilian Guidas de Práctica Clínica 2020, which are the most representative regional guidelines and were not referenced in this article).
We consider that this article leads to erroneous clinical and treatment behaviours, as it is incomplete in terms of treatment guidance in the management of patients treated with glucocorticoids. We suggest reading the recently published modern guidelines cited above.1–5
