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Mind the bone: a protocol for osteoporosis prophylaxis in patients with thyroid eye disease on intravenous methylprednisolone

Eye volume 39, pages 2733–2735 (2025) Cite this article

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Glucocorticoid-induced osteoporosis (GIO) is the most common cause of secondary osteoporosis [1]. It is characterised by rapid bone loss soon after initiation of glucocorticoid therapy with an associated increase in fracture risk within 3–6 months, which is maintained throughout the duration of therapy [2]. Following discontinuation of glucocorticoids, fracture risk declines but may not revert to baseline levels [3]. These effects are dose-dependent and high-dose oral prednisolone (≥7.5 mg/day oral prednisolone over 3 months) or equivalent may increase the 10-year risk of a major osteoporotic fracture by 20% [4]. Although glucocorticoid effects on bone are well-documented, adherence to osteoporosis prophylaxis guidelines by medical practitioners, particularly non-rheumatologists, remains inconsistent [5,6,7,8].

According to the European Group on Graves’ Orbitopathy (EUGOGO), American Thyroid Association (ATA), and European Thyroid Association (ETA), first-line management for moderate-to-severe thyroid eye disease (TED) includes 500 mg intravenous methylprednisolone (IVMP) per week for 6 weeks followed by 250 mg IVMP per week for 6 weeks [9, 10]. TED has an estimated annual incidence of 0.54–0.9 cases/100,000 in men and 2.67–3.3 cases/100,000 in women; 5-6% of cases fall into the moderate-to-severe category [11, 12]. Therefore, a significant number of patients with TED are exposed to high-dose steroid (1 mg IVMP is equivalent to 1.25 mg oral prednisolone [13]) for a sustained period. In addition, hyperthyroidism is an independent risk factor for secondary osteoporosis [14]. Despite this, there is no mention of GIO prophylaxis management in the 2021 EUGOGO guidelines or the 2022 consensus statement from the ATA and ETA [9, 10]. Therefore, there may be a lack of awareness of the risk of GIO and how to implement GIO prophylaxis when ophthalmologists encounter these patients.

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Fig. 1: A protocol for osteoporosis prophylaxis in a thyroid eye disease clinic for patients starting intravenous methylprednisolone.
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Authors and Affiliations

  1. Moorfields Eye Hospital, London, UK

    Mumta Kanda, Allan Zhifa Nghiem & Jimmy Uddin

  2. Royal London Hospital, London, UK

    Ali Jawad

Authors
  1. Mumta Kanda
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  2. Allan Zhifa Nghiem
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  3. Ali Jawad
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  4. Jimmy Uddin
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Contributions

MK wrote the manuscript. AN conceptualised the project, supervised the project, and reviewed the manuscript. AJ provided expert opinion for the protocol and the manuscript. JU supervised the project and reviewed the manuscript.

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Correspondence to Mumta Kanda.

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The authors declare no competing interests.

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Kanda, M., Nghiem, A.Z., Jawad, A. et al. Mind the bone: a protocol for osteoporosis prophylaxis in patients with thyroid eye disease on intravenous methylprednisolone. Eye 39, 2733–2735 (2025). https://doi.org/10.1038/s41433-025-03960-6

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