Pediatric rheumatologists discuss osteoporosis in children with chronic inflammatory diseases

Although bone mineral density (BMD) remains useful in tracking a child’s bone health trajectory over time, the diagnosis of osteoporosis in pediatric age groups has shifted from a focus on BMD to a new approach that emphasizes clinical history and fracture identification.

During the session Updates on Osteoporosis in Children with Chronic Inflammatory Diseases, two pediatric rheumatologists reviewed some of the most recent advances and recommendations in the diagnosis, monitoring, and management of bone fragility in children with chronic inflammatory illnesses. The session, which was originally presented Saturday, Nov. 6, can be viewed by registered meeting participants through March 11, 2022.

Leanne Ward, MD, FRCPC, Professor of Pediatrics and Research Chair in Pediatric Bone Health at the University of Ottawa, discussed some of the unique considerations in the diagnosis and management of glucocorticoid-induced osteoporosis (GIO) in children with rheumatologic disease. Vertebral fractures, she said, are the hallmark of GIO in children with inflammatory disorders.

“They occur most frequently in the first two years of steroid therapy and are heralded by discrete predictors in the first year of exposure to steroid therapy,” Dr. Ward said. “And they are frequently asymptomatic, so routine spine imaging is recommended for those at risk.”

In general, she said that children who have been on daily oral or intravenous steroids for three months or more should have annual X-ray, or dual-energy X-ray absorptiometry (DXA) imaging and lumbar spine BMD testing every six months.

“Once an early sign of bone fragility has been identified in a steroid-treated child, the next step is to determine whether the child has the potential to recover from osteoporosis,” Dr. Ward said.

Vertebral body reshaping after a vertebral fracture is a key sign of recovery that mitigates the need for osteoporosis therapy, added Dr. Ward, noting that vertebral body reshaping is growth-mediated, so it’s unique to children with residual growth potential.

When considering treatment, she said the “classic candidate” for GIO therapy is a child with at least one low-trauma vertebral or long bone fracture, plus older age, persistence of risk factors, or unfavorable BMD trajectory.

“However, if a child is symptomatic enough — with pain or loss of mobility — even if they’re younger, even if they have potential to reshape, and even if they have a favorable BMD trajectory, we would consider treating them in the short term to help them get back on their feet,” she said.

Emily von Scheven, MD, MAS, Professor of Pediatrics and Division Chief for Pediatric Rheumatology at the University of California, San Francisco, emphasized the importance of screening and managing bone health in this pediatric population.

“Bone health is important to address in our young patients because of the window of opportunity present during the years of growth,” Dr. von Scheven said. “Any childhood illness, especially if associated with the use of bone-toxic medications such as glucocorticoids, can interfere with achieving normal peak bone mass during this growth phase. Thus, addressing bone health in our pediatric patients is not only important to prevent fractures during childhood, but also to ensure optimal bone health across their lifespan.”

New drugs and new treatment algorithms on the horizon may provide rheumatologists with new tools to protect the bone health of both pediatric and adult patients, she noted. Promising anti-resorptive agents are being developed, including new integrin antagonists, which can interfere with the attachment of osteoclasts to bone matrix and potentially decrease osteoclast action.

“Additionally, new algorithms are being developed for combination therapy and sequential therapy,” Dr. von Scheven said. “It’s been shown that if you give an anabolic agent, you can sometimes incite a secondary bone resorption process. So the idea of co-treating with an anabolic agent followed by an anti-resorptive might be reasonable to make sure you maintain the gains in bone that you see with the anabolics.”