Effects on bone health of glucocorticoid replacement therapy in primary and secondary adrenal insufficiency: A review

This review focuses on the effects of glucocorticoid replacement therapy on bone health in patients with primary and secondary adrenal insufficiency. The negative impact of glucocorticoids on bone is related to a number of factors, namely dose and type of steroid used, duration of therapy, and cumulative dose. Although “substitutive” in nature, GRT often produce cortisol levels that may be over the true physiological range; therefore, patients may be chronically exposed to a slight cortisol excess potentially affecting bone health and increasing the risk of fractures. Glucocorticoids are the first cause of secondary osteoporosis. They act on bone impairing not only bone mineral density (BMD) but also bone quality, so BMD obtained by DXA measurements does not fully reflect the negative effects on the skeleton. We explore scientific literature on this focus. A lot of papers are related to small series of patients studied several years ago; most of these studies evaluated BMD effects and results are often conflicting, with few data about fractures. The recent guidelines suggest, for the replacement therapy of adrenal insufficiency, the use of daily doses of glucocorticoid lower than previously used and new glucocorticoid formulations become available, potentially safer, with lower deleterious effects on bone health.