Association of Potent and Very Potent Topical Corticosteroids and the Risk of Osteoporosis and Major Osteoporotic Fractures

SPS commentary:

A related editorial considers how a clinician should interpret these study results to better inform treatment initiation, dose selection, and duration of treatment for patients who may benefit from topical corticosteroids (TCS). First, although there is a modest association of TCS use with osteoporosis and fracture, it is critical to recognise that this study’s findings do not provide evidence that TCSs at conventional doses (prescribed foremost dermatologic conditions) cause considerable harm. Second, this study does not determine whether the risk of glucocorticoid induced osteoporosis (GIOP) and fractures associated with TCS use differs by underlying disease and disease severity.  Third, absorption of TCSs can differ by location of use on the body, surface area covered, and skin integrity characteristics that can independently influence risk. Fourth, because of the nature of the registry data, this study could not address whether the excess risk of high dose TCS use on GIOP and fractures persists after TCS therapy has been completed or changed to a steroid-free agent.

 

The study clearly indicates that although the risk for GIOP and osteoporosis may be lower with high-dose TCSs than with systemic glucocorticoids, a cumulative dose-response association exists.  To minimise risk for GIOP when a high-dose, very potent TCS is required, it would be prudent to select a TCS regimen that reflects the lowest dose for the shortest duration necessary to manage the underlying medical condition. There are few data to directly guide recommendations for strategies to reduce TCS-related risk for bone loss and fracture. However, adoption of guidelines for prevention of GIOP related to systemic glucocorticoids should be used to target the small subset of patients receiving TCS therapy who have the highest risk for fracture given their high dosage of TCS and/or other osteoporosis risk factors. Also, when the cumulative dose nears the highest thresholds, it might be reasonable to consider switching to a non–glucocorticoid-based treatment to improve patient outcomes.