The steroid lowers your bone density and increases your risk of developing a fragility fracture.
If osteoporosis is thought to be due in part to taking a steroid medicine, it is known as steroid-induced osteoporosis. In fact, the use of steroid medicines is one of the leading causes of osteoporosis. Between 3 and 5 in 10 people who take steroid medicines in the long term will develop a fragility fracture because of osteoporosis if nothing is done to prevent this.
In general, when we are talking about steroid medicines that can cause steroid-induced osteoporosis, we are talking about long-term treatment. Long-term means if you are taking it every day for three months or more, or having shorter courses very frequently. It also mainly refers to being treated with steroid tablets such as prednisolone. Long-term treatment with steroid creams does not carry the same risks of steroid-induced osteoporosis. However, long-term use of high doses of inhaled steroids may possibly also increase your risk of developing steroid-induced osteoporosis. It is not known for sure yet if this is the case or not. For this reason, the dose of steroid in an inhaler is usually kept to a minimum so that it is just high enough to keep your asthma or other respiratory problem under control.
Note: if you are taking long-term high-dose steroid inhalers, you should discuss your risks of developing osteoporosis with your doctor. Using a high-dose steroid inhaler in the long term may possibly also be a risk but this is not known for sure.
What can be done to prevent steroid-induced osteoporosis?
There are a number of things that can be done to reduce your risk of developing steroid-induced 'thinning' of the bones (osteoporosis) if you are taking steroid tablets for three months or more. These may be things that you can change yourself in terms of your lifestyle, as well as treatment with medicines or other measures that your doctor may suggest.
See the leaflet called Osteoporosis for full details on lifestyle factors which can further increase the risk, but briefly the following help to reduce risk:
- Stopping smoking.
- Limiting alcohol intake.
- Taking more exercise (particularly weight-bearing exercise).
- Having an adequate calcium and vitamin D intake, and considering supplements if you are not getting enough calcium and/or vitamin D.
Take the minimum dose of steroids possible for the shortest period of time
In general, the higher the dose of steroid tablets taken in the long term, the higher your risk of developing a fragility fracture. However, saying that, there is not really a safe dose of steroid tablets because even low doses can increase your fracture risk. Talk to your doctor about the dose of steroid tablets that you are taking. Could the amount of steroid be reduced? Is there another way that the steroid medication may be taken rather than as tablets by mouth? For example, steroids applied to the skin or inhaled into the lungs may be an option to treat some conditions. Taking the steroid medication in another way may help to reduce the effect of the steroids on your bones.
How long a course of steroid tablets do you need? You should also discuss this with your doctor. The course of treatment should be as short as possible. However, as mentioned already above, there is often a balance between the risk of side-effects from taking steroid tablets against the symptoms and damage that may result from some diseases if they are not treated with steroids. It may be that it is more risky not to take the steroids. If this is the case, you may be given treatment to protect your bones from the effects of the steroids.
Treatment with medicines may be needed for some people
If you have had a previous fragility fracture, you will usually be offered treatment with medicines to prevent steroid-induced osteoporosis if you are prescribed long-term steroid tablets. This is regardless of your age. If you are an older person, you will also usually be offered preventative treatment with medicines even if you have not had a previous fragility fracture. The medicine usually used to prevent steroid-induced osteoporosis is one of a group of medicines called bisphosphonates.
Otherwise, whether or not preventative treatment with medicines will be suggested will depend on how high the doctor feels your risk is. This may depend on your bone density readings if you have a DEXA scan and/or any other risk factors for osteoporosis that you may have. Your doctor will be able to advise for your particular case.
Further reading and references
Clinical guideline for the prevention and treatment of osteoporosis; National Osteoporosis Guideline group (NOGG) 2017
Osteoporosis: assessing the risk of fragility fracture; NICE Clinical Guideline (August 2012, updated February 2017)
Management of osteoporosis and the prevention of fragility fractures - A national clinical guideline; Scottish Intercollegiate Guidelines Network - SIGN, (March 2015)
Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK; National Osteoporosis Guideline Group (updated 2014)
Bisphosphonates for treating osteoporosis; NICE Technology Appraisal Guidance, August 2017
Denosumab for the prevention of osteoporotic fractures in postmenopausal women; NICE Technology Appraisal Guidance, October 2010
Avenell A, Mak JC, O'Connell D; Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 144:CD000227. doi: 10.1002/14651858.CD000227.pub4.
Black DM, Rosen CJ; Clinical Practice. Postmenopausal Osteoporosis. N Engl J Med. 2016 Jan 21374(3):254-62. doi: 10.1056/NEJMcp1513724.
Hip fracture: management; NICE Guideline (June 2011, updated May 2017)
Management of hip fracture in older people; Scottish Intercollegiate Guidelines Network - SIGN (June 2009)
Vitamin D and health; Scientific Advisory Committee on Nutrition (July 2016)
Sunlight exposure: risks and benefits; NICE Guidance (February 2016)
Santesso N, Carrasco-Labra A, Brignardello-Petersen R; Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014 Mar 31(3):CD001255. doi: 10.1002/14651858.CD001255.pub5.
Several people have posted recently that they have been able to reverse their measured (DXA scan) bone thinning through natural means - nutrition, appropriate supplements and exercise. It would be...Anhaga
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