Steroid-induced osteoporosis: protecting your bones on long-term steroid tablets

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. The NHS says it develops slowly over several years and is often only diagnosed when a fall or sudden impact causes a fracture, most commonly of the wrist, hip or spinal bones. Steroid tablets are not the only cause, but the NHS lists taking high-dose steroid tablets for more than 3 months as one of the factors that increases risk, and notes that they are widely used for conditions such as arthritis and asthma.

These are the corticosteroid medicines, such as prednisolone, that are swallowed or injected and act throughout the body. They are different from the steroid inhalers used for asthma preventers and from creams. The UK clinical guideline for the prevention and treatment of osteoporosis describes glucocorticoid-induced osteoporosis as a distinct situation with its own recommendations.

The UK guideline states that oral glucocorticoid therapy increases fracture risk in a dose-dependent manner, and that the extra risk is not explained by bone density alone. Bone loss and increased fracture risk occur early after steroids are started. It adds that current glucocorticoid treatment by mouth for 3 months or more is one of the clinical risk factors in the FRAX tool.

Other factors add to the risk. The NHS lists a family history of osteoporosis or hip fracture in a parent, low body mass index, an eating disorder, heavy drinking and smoking, rheumatoid arthritis, malabsorption problems such as coeliac disease and Crohn's disease, long periods of inactivity, and some medicines used to treat breast and prostate cancer. The condition being treated with steroids, such as an inflammatory disease, can itself weaken bone.

The NHS says osteoporosis is not usually painful until a bone is broken, and that broken bones in the spine are a common cause of long-term pain. Sometimes a cough or sneeze can cause a broken rib or partial collapse of a spinal bone, and some people develop a stooped posture. Because there are often no warning signs, protection is based on assessing risk rather than waiting for symptoms. New sudden back pain in someone on long-term steroids should be reported to a GP.

The NHS explains that a doctor can estimate the future risk of a fracture using an online tool such as FRAX or QFracture, and may refer you for a bone density (DEXA) scan, a short painless test that takes 10 to 20 minutes. A T score below -2.5 is defined as osteoporosis and between -1 and -2.5 as osteopenia. The UK guideline notes that FRAX can be adjusted upwards for higher steroid doses: for doses above 7.5 mg a day, the probability of a major osteoporotic fracture is adjusted upward by about 15% and of hip fracture by about 20%.

The guideline recommends vertebral fracture assessment, an imaging check for spinal fractures, in postmenopausal women and men aged 50 or over with recent or current long-term oral glucocorticoid therapy, among other criteria.

According to the UK guideline, because bone loss happens early, bone-protective treatment should be started at the same time as glucocorticoid therapy, without waiting for bone density assessment, in anyone with a prior fragility fracture, in women aged 70 or over, in postmenopausal women and men aged 50 or over prescribed high doses (7.5 mg a day of prednisolone or equivalent over 3 months), and in postmenopausal women and men aged 50 or over whose FRAX probability exceeds the intervention threshold.

For people on high-dose steroids, the guideline advises urgent referral to an osteoporosis specialist given the rapid bone loss after starting, and says that if any delay is expected an oral bisphosphonate should be started in the meantime. It also states that in the UK, assessment and management have been inadequate in long-term users of oral glucocorticoids, so it is reasonable to ask your doctor whether your bones have been considered.

The UK guideline says oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate are the most cost-effective first-line options, and that alendronate 70 mg once weekly is recommended for glucocorticoid-induced osteoporosis. Other approved options listed are denosumab and teriparatide. The NHS explains how bisphosphonates work: they slow the rate at which bone is broken down. They are taken on an empty stomach with a full glass of water while staying upright for 30 minutes, and usually take 6 to 12 months to work.

The NHS also advises making sure you get enough calcium and vitamin D. The recommended amount for most adults is 700 mg of calcium a day, and a daily supplement containing 10 micrograms of vitamin D is advised in autumn and winter. Oral bisphosphonates are not suitable for people with oesophageal problems such as stricture or achalasia, or who cannot sit or stand upright for 30 to 60 minutes. The NHS notes that if you have a history of dental problems you may need a check-up before starting bisphosphonates.

The NHS suggests regular weight-bearing exercise, a diet rich in calcium and vitamin D, stopping smoking and reducing alcohol. To reduce the chance of falls it suggests removing hazards at home and having regular sight and hearing tests. Never stop or reduce steroid tablets without medical advice. If your steroids can be reduced, or an alternative given, that is a decision for the prescriber who is managing the underlying condition.

On the NHS, steroid bone protection is usually started by the GP or the specialist who prescribes the steroids, with referral to an osteoporosis or rheumatology service for higher-risk cases. Private DEXA scans are widely available, but the decision to treat depends on a full risk assessment, so any result should be reviewed by the clinician who is managing your steroid treatment.