Osteoporosis and PCP Prophylaxis in Myasthenia Gravis Patients on High-Dose Prednisone

Osteoporosis Prophylaxis

• The American College of Rheumatology strongly recommends oral bisphosphonates for adults ≥40 years at very high fracture risk (prednisone ≥30 mg daily for ≥30 days) 2, 3
• The British Journal of Dermatology recommends starting calcium and vitamin D supplementation immediately at initiation of glucocorticoid treatment, regardless of fracture risk stratification 1
• For patients ≥40 years on high-dose steroids, the fracture risk is immediate and substantial, and bisphosphonate initiation should not be delayed 2, 3
• The American College of Rheumatology conditionally recommends PTH/PTHrP over anti-resorptive agents for very high-risk patients, but strongly recommends oral bisphosphonates as a minimum intervention 2, 3

PCP Prophylaxis

• The National Comprehensive Cancer Network recommends prophylaxis for patients receiving ≥20 mg prednisone daily for ≥4 weeks 4
• Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred prophylactic agent, providing a 91% reduction in PJP occurrence and 83% reduction in PJP-related mortality 5, 4
• Standard prophylactic dosing: TMP-SMX 800/160 mg (double-strength) three times weekly 5
• If rituximab is added at any point, extend prophylaxis for at least 6 months after the last rituximab dose 4

Duration of Prophylaxis

• Continue calcium/vitamin D throughout the entire duration of glucocorticoid therapy 1
• Continue bisphosphonates as long as the patient remains on glucocorticoids and meets fracture risk criteria 2
• Continue TMP-SMX prophylaxis throughout the entire duration of prednisone ≥20 mg daily 4
• If prednisone is tapered below 20 mg daily and no other immunosuppressants are used, prophylaxis can be discontinued 4