Steroids and osteoporosis

Steroids (doctors also call them glucocorticoids or corticosteroids; prednisolone is one example) are strong anti-inflammatories and play an important part in treating diseases such as rheumatoid arthritis, lupus and vasculitis. But long-term use has costs, and one of them is weakened bone. This article explains why this happens and what is done about it, so that you need not fear steroids or feel you have to stop them yourself.

Why do steroids weaken bone?

The NHS counts osteoporosis among the known side effects of taking higher doses of steroids, or taking them for longer, along with more infections, mood changes, high blood sugar and blood pressure, and eye problems such as cataracts. The ACR writes that steroids used for autoimmune diseases and inflammatory arthritis can cause rapid bone loss, even in the first six months of use, and raise the risk of fracture.

If the dose is small and the time short, the risk is lower. The NHS says side effects are less likely with short-term use or a low dose and usually go away when treatment ends. For rheumatoid arthritis, the NHS also says steroids are usually taken for a short time, for fast relief, for example until a disease-modifying medicine starts to work. NIAMS also says steroids are used at the lowest effective dose. In some diseases, such as giant cell arteritis, the NHS says steroids are sometimes needed for a few years, and some people need them for longer.

Who is more at risk?

The ACR names these factors: older age, smoking, heavy alcohol use, a small body frame, a family history of osteoporosis, a fracture from a minor blow after age 50, and taking steroids at a dose and for a length of time that the doctor considers risky. Your doctor knows the exact dose and duration that matter.

What can be done to protect bone?

The ACR mentions these for prevention:

• The lowest possible dose. The ACR stresses using the lowest dose of steroids needed to control the disease. Changing the dose is only the doctor’s job.
• Calcium and vitamin D. The ACR counts these as pillars of prevention and treatment. The NHS also writes that calcium and vitamin D may help prevent osteoporosis in people taking steroids. The doctor decides the amount and whether it is needed; do not start high-dose supplements on your own without advice.
• Weight-bearing activity. The ACR gives the example of walking on most days. (Adjust it with your doctor or physiotherapist according to the state of your joints.)
• Quitting smoking and preventing falls.
• Bone density testing. The ACR says osteoporosis is identified with a bone density test (BMD or DXA). It is a quick, painless test. Pregnant women should not have it.
• Bone-specific medicines. The ACR says several prescription medicines are approved for prevention or treatment, and in giant cell arteritis the NHS names bone-protecting medicines (bisphosphonates). Whether you need them is the doctor’s decision.

Do not stop steroids on your own

After reading this, you may be tempted to stop the tablets. Do not do that.

The NHS writes plainly: “Do not suddenly stop taking steroid medicine unless your doctor tells you it’s safe to stop. Suddenly stopping treatment with steroids can make you very unwell.” If you have taken them for more than three weeks, or the dose was high, the dose must be reduced gradually. Sudden stopping may bring tiredness, nausea, dizziness, loss of appetite and joint pain, and may make the disease active again. If you feel unwell after stopping or forgetting the medicine, or vomiting means you cannot keep your tablets down, call the same day (see the guide “When should I call urgently?”). ACR also says you should work with your doctor so that the lowest necessary dose is used and other medicines are considered, rather than deciding yourself.

For giant cell arteritis too, the NHS says do not stop steroids suddenly; a high dose is given first and, after improvement, it comes down to a lower dose. In this disease the NHS also mentions bone-protecting medicines.

What else should you know?

• Steroid card. The NHS says if you take steroids for more than three weeks, or a high dose has been prescribed, your doctor or pharmacist should give you a card showing that it must not be stopped suddenly, and you should always carry it.
• Infection. Steroids make infection more likely. The NHS says to tell your doctor straight away if you come into contact with chickenpox, shingles or measles.
• Mood. The NHS says changes in mental state may occur. Tell your doctor early.
• Sudden back pain. The Arthritis Foundation says sudden spinal pain in people taking steroids may be a vertebral fracture. If you get such pain, see a doctor the same day.

Talking with your doctor

Ask your doctor these questions:

• Why do I need steroids, and what is the plan?
• How long will I take them, and how fast will the dose come down?
• Should my bone density be checked?
• What should I do to protect my bones? Do I need a supplement?
• If I become ill or get an infection, whom should I contact?