Table 4.

Bone and cardiometabolic scenarios in adult patients with 21OHD and suggested clinical actions

Scenario	Recommended clinical action
Decreased BMD	Optimize GC doses and regimens Optimize lifestylea Add calcium and vitamin D supplementation as appropriate Consider adding estrogen (females)b or testosterone (males) if low In older individuals consider bisphosphonate or denosumab
Osteoporotic fracture	Same as above Consider teriparatide
Increased BMI and/or waist circumference	Optimize GC doses and regimens Optimize lifestylea Consider weight reducing program Consider gastric-by-pass or equivalent if >40 kg/m2
Increased blood pressure	Decrease fludrocortisone dose (if renin/PRA is suppressed or within reference limits) Optimize lifestylea Add an antihypertensive drug, eg, an ACE-inhibitor or ARB
Increased glucose level (due to insulin resistance) and/or type 2 diabetes	Optimize GC doses and regimens Optimize lifestylea Add metformin Consider other glucose-lowering medications
Increased lipid levels	Optimize lifestylea Add a statin

Exercise, appropriate diet, no tobacco, alcohol in moderation.

Estrogen can be given as oral contraceptive pills in young fertile women. In young postmenopausal women hormone replacement therapy can be considered.

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BMD, bone mineral density; BMI, body mass index; GC, glucocorticoid; PRA, plasma renin activity.