In reply
We read with interest the results and conclusions based on the chart review of patients receiving long-term steroid treatment by Drs Edin and Arsad Karcic. In our cohort of 229 long-term corticosteroid users,1 only 18% (41/229) were receiving some form of osteoporosis prevention (hormone replacement, bisphosphonate, or vitamin D analogue). Only 4% (3/72) of the men were receiving osteoporosis prevention, compared with 24% (38/157) of the women. On further analysis, we found that, apart from sex, none of the other variables, such as age, current steroid use, duration of steroid use, bone density, or presence of vertebral deformity, was predictive of whether treatment for osteoporosis prevention had been initiated. The ad hoc basis on which treatment for osteoporosis prevention was initiated in our study group is in contrast to the clear recommendation outlined in recent guidelines. A guideline directed at patients using 7.5 mg/d or more of prednisone (equivalent) that was developed in the United Kingdom recommends treatment for patients who have one or more of the following criteria: presence of osteoporotic fractures, age older than 65 years (irrespective of sex), strong risk factors for osteoporosis, and low bone density.2 The results of our study also provide an insight into what might be happening in everyday clinical practice. In a survey of Australian rheumatologists, more than 80% said they would initiate treatment (hormone replacement, bisphosphonate, or vitamin D analogue) to prevent osteoporosis in postmenopausal women who are starting corticosteroid therapy.3 In practice, however, this figure seems to be much lower.