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The HORIZON Study: Bisphosphonates for Patients on Corticosteroids

Once-yearly infusion of a bisphosphonate may be more effective and more convenient than daily bisphosphonate for preventing and treating glucocorticortoid-induced osteroporosis.

I have often written about the need to prevent and treat osteopenia and osteoporosis in patients receiving corticosteroid therapy for chronic skin disease. Lupus erythematosus, dermatomyositis, chronic eczemas, pemphigus, and pemphigoid (among other conditions) are often managed with systemic corticosteroids. Patients taking the equivalent of 5 mg/day or more of prednisone are at risk and should be prescribed oral calcium, vitamin D, and a bisphosphonate. Standard bisphosphonate dosing schedules include 70 mg/week of alendronate, 35 mg/week (or 150 mg/month) of risedronate, or 150 mg/month of ibandronate. For patients who fail to benefit from bisphosphonates, subcutaneous injection of 20 µg/day of teriparatide may be more effective (see JW Dermatol Nov 14 2007).

In a randomized, double-blind, double-dummy, noninferiority study, researchers compared 5 mg/day of risedronate with a single intravenous infusion of 5 mg of zoledronic acid in 833 patients who were followed for up to 1 year. They found the single infusion not inferior, and perhaps superior, to daily dosing in preserving bone-mineral density. Zoledronic acid recipients had more adverse reactions than daily risedronate recipients in the first few days following infusion, but the infusion otherwise had no important toxicity.

Comment: In this relatively short-term study, infusion of zoledronic acid was compared with a daily bisphosphonate, which is rarely used in clinical practice. Although a one-time infusion was not inferior, and may have been superior, for bone density scores, the occurrence of fracture was not assessed in these patients, which, after all, is the process that must be prevented. The cost of these agents is roughly the same (yearly, about US$1320 for risedronate and about US$1125 for zoledronic acid). Therefore, patient convenience favors the use of a once-yearly infusion over daily, weekly, or even monthly oral use.

— Jeffrey P. Callen, MD

Published in Journal Watch Dermatology May 1, 2009

Citation(s):

Reid DM et al. Zoledronic acid and risedronate in the prevention and treatment of glucocorticoid-induced osteoporosis (HORIZON): A multicentre, double-blind, double-dummy, randomised controlled trial. Lancet 2009 Apr 11; 373:1253.

• Medline abstract (Free)

Gennari L and Bilezikian JP. Glucocorticoid-induced osteoporosis: Hope on the HORIZON. Lancet 2009 Apr 11; 373:1225.

• Medline abstract (Free)

Reader Remarks:

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• how about pediatric patients
  TL Lee, 11 May 2009 1:52 PM EST
  what is your recommendation in pediatrics patients receiving high dose corticosteroid?
• pediatric patients
  Jeffrey Callen, University of Louisville; Deputy and Feature Editor, Journal Watch Dermatology, 13 May 2009 2:41 PM EST
  Bone loss is a potential problem for these patients as well, but even more of an issue is the stunting... [more]