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Table 11 ACR pharmacological recommendations for the prevention and management of GC-induced osteoporosis in adults*[115]

From: A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy

Postmenopausal women and men age ≥50 years starting GC therapy of ≥3 months’ duration, or prevalent GC therapy of ≥3 months’ duration
Low-risk (10-year fracture risk < 10%) • GC dose < 7.5 mg/day of prednisone or equivalent:
   → no pharmacologic treatment
• GC dose ≥ 7.5 mg/day of prednisone or equivalent:
   → alendronate, risedronate or zoledronic acid
Medium-risk (10-year fracture risk = 10-20%) • GC dose < 7.5 mg/day of prednisone or equivalent:
   → alendronate or risedronate
• GC dose ≥ 7.5 mg/day of prednisone or equivalent:
   → alendronate, risedronate or zoledronic acid
High-risk (10-year fracture risk > 20%) • Any dose or duration of GCs justifies initiating prescription therapy
 ▪ If GC dose < 5 mg/day of prednisone or equivalent for ≤ 1 month:
   → alendronate, risedronate, or zoledronic acid
 ▪ If GC dose ≥ 5 mg/day of prednisone or equivalent for ≤ 1 month or any GC dose for > 1 month:
   → alendronate, risedronate, zoledronic acid or teriparatide
Premenopausal women and men < 50 years with a history of fragility fracture
GC duration: 1–3 months  
Non-childbearing potential: • If prednisone (or equivalent) ≥ 5 mg/day: alendronate or risedronate
• If prednisone (or equivalent) ≥ 7.5 mg/day: zoledronic acid
Childbearing potential: • No consensus
GC duration: >3 months  
Non-childbearing potential: • Any dose: alendronate, risedronate, zoledronic acid, teriparatide
Childbearing potential: • If prednisone (or equivalent) < 7.5 mg/day: no consensus
• If prednisone (or equivalent) ≥ 7.5 mg/day: alendronate, risedronate, teriparatide
  1. *See text for guidelines related to children.
  2. In clinical practice, teriparatide is generally reserved for bisphosphonate treatment failures (i.e., new vertebral fracture or ≥2 non-vertebral fractures after adherence to 12 months of bisphosphonate treatment).