Do the benefits of alendronate for premenopausal women on high-dose glucocorticoids outweigh the risks?

Few data are available on the prevention of fracture in glucocorticoid-treated premenopausal women with autoimmune disorders such as systemic lupus erythematosus. In this setting, Okada et al. compared the effect of coadministration of alfacalcidol alone with that of alfacalcidol combined with alendronate. After 12 months of treatment, lumbar spine bone mineral density increased by 1.7% in the combination group, but decreased by 9.9% in the alfacalcidol-only group (P <0.001). Importantly, although no vertebral fractures were observed in the alendronate group, four patients in the alfacalcidol-only group experienced a vertebral fracture within 12-18 months of treatment. Although these data suggest that alendronate improves bone mineral density, we do not recommend the routine use of bisphosphonates in premenopausal women. Our reasons include the long-term skeletal retention of bisphosphonates, and the possible inhibitory effects on fetal skeletal maturation in pregnant patients. In addition, recent data suggest that premenopausal women who undergo glucocorticoid therapy have a low 10-year absolute risk of fracture.