What You Need to Know About Corticosteroid-Induced Osteoporosis

Corticosteroids are one type of steroid medication. Sometimes the term “steroid” is used interchangeably with “corticosteroid.”

About 1% of the general population is estimated to receive long-term treatment with corticosteroids. Steroids such as prednisone are used as therapy for many inflammatory and autoimmune diseases, including:

• asthma
• rheumatoid arthritis
• lupus
• inflammatory bowel disease

They are also used to treat many allergic conditions. While steroids are generally effective in treating such ailments, they are also the most common cause of drug-induced osteoporosis.

Corticosteroids and Bone Remodeling

Corticosteroids affect calcium and bone metabolism in many ways:

• Steroids increase the natural rate of bone breakdown (resorption)
• Steroids decrease bone formation
• Steroids decrease the amount of calcium absorbed by the intestine
• Steroids increase calcium excretion through the kidneys

Steroids work directly on target tissues in bone to increase resorption and decrease formation. Their effects on calcium result in an indirect increase in destruction by triggering the parathyroid glands to increase the secretion of parathyroid hormone (PTH). This condition is known as secondary hyperparathyroidism. Elevated PTH levels result in increased bone breakdown, as the body attempts to rectify low circulating calcium levels by releasing calcium from the bones into the blood.

Corticosteroids can also decrease the levels of the sex hormones:

• estrogen (in women)
• testosterone (in men)

The resulting decreases are associated with increased bone loss.

Corticosteroids also cause muscle weakness, which may lead to inactivity and additional bone loss.

Patterns of Bone Loss

There are two types of bone tissue: cortical and trabecular.

• Cortical bone forms the outer shell of bone and comprises 80% of the skeleton.
• Trabecular bone (the remaining 20%) is found inside the bone.

Each bone in the skeleton contains both types of bone, but their proportions vary. Corticosteroids primarily cause bone loss in those areas of the skeleton that are rich in trabecular bone, such as the spine.

Dose and Duration

Bone loss occurs most rapidly in the first 3–6 months of therapy and is dependent on both:

• dose
• duration

Other risk factors for osteoporosis may have an additive effect on bone loss, such as:

• age
• gender
• underlying disease

For example, elderly men on steroids may experience even greater bone loss and risk for fracture than middle-aged men. Without preventive measures, an estimated 10%–20% of people on long-term corticosteroids will experience a fracture.

The dose of corticosteroids is a strong predictor of fracture risk. While it is not clear whether there is a low-dose threshold below which bone loss does not occur, recent studies have found inhaled steroids to have little to no effect on bone density when administered in standard doses and apart from systemic steroids.​

Osteoporosis Management

Steroid-induced osteoporosis is both preventable and treatable. The American College of Rheumatology (ACR), people on corticosteroids should have a bone mineral density test performed. This test will provide a baseline measurement from which to monitor subsequent changes in bone mass. The ACR also recommends a daily intake of 1,000–1,200 milligrams of calcium and 600–800 international units (15–20 micrograms) of vitamin D. Calcium and vitamin D can help maintain calcium balance and normal parathyroid hormone levels, and can even preserve bone mass in some patients on low-dose steroid therapy.

Osteoporosis Drugs

For people at higher risk of fractures, ACR recommends a class of medications called bisphosphonates for prevention and treatment of osteoporosis. Bisphosphonates approved by the FDA for corticosteroid-induced osteoporosis include:

• Actonel (risedronate)
• Fosamax (alendronate)
• Reclast (zoledronic acid)

In corticosteroid users, these drugs deliver beneficial effects on bone mineral density of the spine and hip and are associated with a decrease in fractures.

While bisphosphonates are ACR’s top recommendation for people at higher risk of fractures, there are a couple of other drugs approved for corticosteroid-induced osteoporosis, both given as subcutaneous injections:

• Prolia (denosumab)
• Forteo (teriparatide)

Estrogen therapy and Miacalcin (calcitonin) may help preserve spinal bone mass in postmenopausal women on corticosteroids, but neither is FDA-approved for corticosteroid-induced osteoporosis.

Lifestyle Modifications

• Eliminating smoking and alcohol are important in reducing the risk of steroid-induced osteoporosis.
• Physical activity and exercise can help to preserve bone and muscle mass while increasing muscle strength and reducing the risk of falls.
• Slip and fall prevention is of particular significance for elderly individuals and for those who have experienced steroid-induced muscle weakness.

A Word From Verywell

Osteoporosis prevention measures should begin early, ideally at the onset of corticosteroid therapy. Experts recommend using the lowest dose of steroid for the shortest period of time possible and, when feasible, inhaled or topical corticosteroids should be utilized.