TY - JOUR T1 - Bisphosphonates in Patients with Glucocorticoids: Time for Implementation JF - The Journal of Rheumatology JO - J Rheumatol SP - 1570 LP - 1572 DO - 10.3899/jrheum.090535 VL - 36 IS - 8 AU - WILLEM F. LEMS Y1 - 2009/08/01 UR - http://www.jrheum.org/content/36/8/1570.abstract N2 - Use of glucocorticoids (GC) may have devastating effects on bone quality1. From earlier histomorphometric data, we know that bone formation is inhibited by direct suppression of osteoblast function during the use of GC, while bone resorption is unchanged or even elevated, at least partly related to decreased intestinal calcium absorption, elevated urinary calcium excretion, and a tendency to secondary hyperparathyroidism2,3. However, exciting new data provide additional insights into the pathogenesis of Glucocorticoid Induced OsteoPorosis (GIOP)2,3: (1) upregulation of the Wnt inhibitor Dickkopf-1, leading to inhibition of bone formation; (2) increased apoptosis of osteoblasts and osteocytes; (3) differentiation of mesenchymal stem cells into the direction of adipocytes, instead of into osteoblasts; (4) elevated lifespan of osteoclasts, due to decreased apoptosis; and (5) upregulation of expression of RANKL in osteoblasts (and downregulation of osteoprotegerin).Nevertheless, it is important to realize that the (negative) direct and indirect effects of GC on bone are counteracted by the immunosuppressive effects of GC on the underlying disease2,3. Another complicating factor is that use of GC and the underlying disease may both be associated with muscular weakness and, subsequently, increased risk of falling.Use of GC is associated with bone loss, particularly in the early phase of treatment, when the dosage of GC is usually high and the underlying disease for which the GC are prescribed is active. In contrast, in the chronic phase, bone loss may be mild in GC-treated patients, related to the use of lower dosages of GC and to low or preferably absent disease activity.In addition, use of GC is also associated with elevated risk of fracture: In a retrospective cohort study with 244,235 GC-treated patients and the same number of age and sex matched controls, the fracture … Address correspondence to Prof. Lems. E-mail: wf.lems{at}vumc.nl ER -