Table 2.

Summary of the BBC recommendations for GIOP in adults.

TOPIC	RECOMMENDATION
Appropriate use of glucocorticoids	1. To prevent GIOP and other complications of long-term glucocorticoid use, we recommend using the lowest effective dose for the shortest amount of time (strong recommendation, high-quality evidence).
	2. We recommend administering glucocorticoids locally rather than systemically when this may be equally effective (strong recommendation, moderate quality evidence).
	3. We suggest early consideration of equally safe and effective glucocorticoid-sparing alternatives (weak recommendation, low-quality evidence).
	4. We suggest that policymakers, scientific societies and care organizations at all levels prioritize implementation of strategies to close the treatment gap in GIOP (weak recommendation, low-quality evidence).
Non-pharmacological management	5. We recommend educating all glucocorticoid-treated patients regarding the risk of osteoporosis and fractures and strategies to avoid those risks (strong recommendation, low-quality evidence).
	6. We recommend eating a balanced diet, exercising regularly, keeping weight within the recommended range, stopping smoking, and preventing alcohol abuse as important lifestyle measures for all adults, and a fortiori for patients receiving glucocorticoids (strong recommendation, low-quality evidence).
	7. We suggest a falls risk assessment in older adult glucocorticoid users, and implementation of evidence-based strategies to reduce the risk of falling in people at increased risk (weak recommendation, low-quality evidence).
	8. Given the lack of evidence to support symptomatic or functional benefit, and possible risk of complications, we recommend against routine vertebroplasty or kyphoplasty in GIOP patients with vertebral compression fractures (strong recommendation, moderate quality evidence).
Laboratory evaluation	9. We suggest a basic biochemical evaluation for other secondary causes of osteoporosis in all glucocorticoid users (preferably before the start of glucocorticoid therapy), regardless of their fracture risk (weak recommendation, low-quality evidence).
Fracture risk assessment and treatment eligibility	10. We recommend fracture risk assessment using clinical risk factors, vertebral fracture assessment and DXA to guide treatment decisions in GIOP (strong recommendation, moderate quality evidence).
	11. We recommend early GIOP prevention in post-menopausal women and men or women aged > 40 years with very high fracture risk (prior vertebral or hip fracture, T-score ≤ -2.5), and for those at high fracture risk (increased FRAX® score, T-score ≤-1.5 or use of ≥ 7.5 mg prednisolone equivalents/day) (strong recommendation, moderate quality evidence).
	12. We suggest considering early GIOP prevention in pre-menopausal women or men aged < 40 years with high to very high fracture risk (weak recommendation, low-quality evidence).
Calcium and vitamin D	13. In adults at risk of bone loss or fractures (which includes glucocorticoid users), we recommend an optimal total daily calcium intake from 1200 to 2000 mg (preferably from dairy or other nutritional sources), together with vitamin D supplements of 800 – 1000 IU/day to achieve a total 25-hydroxyvitamin D target level of 50-125 nmol/L (20-50 ng/mL) (strong recommendation, low-quality evidence).
Antiresorptive and bone anabolic drugs	14. We recommend alendronate, risedronate, zoledronate, denosumab or teriparatide for GIOP prevention (strong recommendation, high-quality evidence).
	15. We suggest considering oral bisphosphonates in GIOP patients at high fracture risk, and teriparatide, denosumab or zoledronate in GIOP patients at very high fracture risk. Nevertheless, we suggest tailoring the choice between treatments not only according to the risk of fractures, but also according to contraindications, patient preference, cost and the possibility of poor compliance (weak recommendation, moderate quality evidence).
Follow-up and monitoring	16. We suggest that follow-up in GIOP should focus on adherence to GIOP preventive and treatment measures, and fracture risk re-evaluation at each visit (weak recommendation, low-quality evidence).
	17. We suggest BMD monitoring by DXA and vertebral fracture identification one year after glucocorticoid initiation. Thereafter, individualized monitoring intervals might be considered. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy (weak recommendation, low-quality evidence).
	18. Trabecular bone score (TBS) might be considered during GIOP monitoring, however, the evidence is currently insufficient to alter treatment based on TBS alone (weak recommendation, low-quality evidence).
	19. BTMs may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP (weak recommendation, moderate quality evidence).
	20. When glucocorticoids are discontinued, we recommend a re-evaluation of fracture risk to guide the decision to continue or stop GIOP prevention (strong recommendation, moderate quality evidence).