Purpose: Oral corticosteroid therapy increases a patient's subsequent risk for hip fracture. Although hip fracture risk among white women is higher than white men, hip fracture mortality is higher among white men. We sought to quantify the tradeoffs between hip fracture incidence and mortality in both white men and white women being treated with oral corticosteroids.

Method: We developed a Markov model to compare hip fracture outcomes over a lifetime for 50-year-old patients undergoing oral corticosteroid therapy vs. comparable patients not on therapy. Annual hip fracture rates for untreated patients were derived from the literature and were a function of age and gender. The annual risk of hip fracture among men and women receiving oral corticosteriods (7.5-10mg/day) was estimated from literature. Hip fracture-specific mortality rates depended on the age of fracture and the time since fracture. The first-year fracture-specific mortality rate among males/females was 0.15/0.03 for hip fractures occurring before age 75, 0.24/0.12 for hip fractures occurring at ages 75-84, and 0.41/0.13 for fractures occurring at age 85 or older. Fracture-specific mortality rates beyond the first year were similar for men and women, although generally higher for women. We used the US life tables for other-cause mortality.

Results: We projected that, out of 1,000 50-year-old persons at average risk for hip fracture, 97 men and 212 women will experience a hip fracture during their lifetime, and 53 men and 86 women will die of their hip fracture. The increased number of hip fractures resulting from taking high-dose oral corticosteroids was 99 for men and 181 for women. The increased number of hip fracture deaths resulting from taking high-dose oral corticosteroids was 54 for men and 79 for women. While the induced hip fracture incidence burden is 82% greater for white women compared with white men, the induced hip fracture mortality burden is only 46% greater.

Conclusion: Focus on hip fracture incidence as the primary side effect associated with oral corticosteroids may obscure the relative burden on white men caused by fracture-related mortality. Formal incorporation of the downstream risks show that the differences between white men and white women in terms of hip fracture outcomes are diminished for hip fracture death.