There
is an expanding list of drugs for which there are concerns regarding adverse
skeletal effects. The effect of long-term use of glucocorticoid drugs to cause
accelerated bone loss and increase the risk of fracture is well recognized. For
some drugs (TKIs, calcineurin inhibitors and loop diuretics), the available
data are inconsistent and/or do not support a definite adverse skeletal effect.
Patients receiving these drugs can be managed in line with guidelines for the
general population (See table). Other drugs (SSRIs, antipsychotic drugs, AEDs
and PPIs) do not seem to affect bone metabolism or BMD, but there is evidence
for increased fracture risk. However, the evidence is limited to observational
data, and any relationship may be attributable either to nonbone effects of the
drug or effects of the underlying condition to increase fracture rate. In these
patients, evaluation for other risk factors for fracture and management of
these risk factors should be considered. In a third group (depot MPA,
chemotherapy and ART), there is evidence for increased bone loss and/or
fracture, but the patient population is generally at low risk for fracture. In
these cases, patients may require an assessment of risk, but will rarely
require specific treatment for fracture risk reduction. In the last group
(aromatase inhibitors, GnRH agonists and thiazolidinediones), there is evidence
of increased risk of bone loss and/or fracture, and the drugs are more
frequently prescribed to individuals at higher baseline fracture risk. Patients
receiving these drugs require risk assessment and those at high risk of
fracture should receive alternative treatments (or "add-back" HRT in
the case of GnRH agonists) or, if necessary, specific treatment for
osteoporosis.
Table:
Summary of management recommendations
|
||
Example drugs
|
Evidence for risk
|
Management recommendations
|
Tyrosine kinase inhibitors
Calcineurin inhibitors Loop diuretics |
No adverse
skeletal effect or data inconsistent |
Manage as per general population
|
Selective serotonin re-uptake
inhibitors (SSRIs)
Antipsychotics Anti-epileptic drugs Proton pump inhibitors |
Evidence for increased fracture
risk but fracture risk seems to relate to nonbone effects of the drug or
effects of the underlying condition
|
Evaluate for other risk factors
for fracture and manage these risk factors
|
Depot medroxyprogesterone acetate
Chemotherapy Antiretroviral therapy |
Evidence for increased bone
loss and/or fracture, but low risk population |
Assessment of fracture risk, but
will rarely require specific treatment
|
Aromatase inhibitors
Gonadotrophin hormone-releasing hormone agonists Thiazolidinediones |
Evidence for increased risk of
bone loss and/or fracture, and the drugs are more frequently prescribed to
individuals at higher baseline fracture risk
|
Assessment of fracture risk and
those at high risk should receive alternative treatments and/or specific
treatment for osteoporosis.
|
The
conclusions and table are from a longer article, “Adverse Skeletal Effects of
Drugs – Beyond Glucocorticoids,” by Susannah O'Sullivan and Andrew Grey, Clin
Endocrinol. 2015;82(1):12-22.
