CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Osteoporosis - preventing steroid-induced - Management
Basis for recommendation
These recommendations are based on the Royal College of Physicians guideline, Glucocorticoid-induced osteoporosis [RCP, 2002].
Lifestyle advice
- These recommendations are pragmatic and have been extrapolated from trials showing that immobility, smoking, and alcohol consumption (more than 2 units per day) are associated with an increased risk of fracture in postmenopausal women with osteoporosis.
Stopping or reducing the dose, duration, and frequency of corticosteroids
- There is some trial evidence that the effects of corticosteroids on bone mineral density (BMD) are at least partially reversible on stopping treatment.
- There is a dose-dependent relationship between corticosteroid use and fracture risk. However, the increased risk of vertebral fractures, even for doses of prednisolone between 2.5 mg and 7.5 mg per day, indicates that there is no 'safe dose' of oral corticosteroids.
- Treatment with corticosteroids for periods as short as 3 months may result in increased fracture risk. Studies conducted in people taking corticosteroids for at least 6 months have shown bone loss to be greatest in the first few months after starting treatment (for example, as high as 30% in the first 6 months).
- Evidence that bone loss is related to the cumulative dose of corticosteroids provides a strong rationale for considering preventive measures in individuals receiving intermittent courses of oral prednisolone over longer periods of time.
- More than three or four courses of corticosteroids taken in the previous 12 months is considered to be equivalent to more than 3 months of continuous treatment. If the intermittent courses are spread over a much longer term, then this is not regarded as such an important risk factor [Francis, Personal Communication, 2006].
BMD and risk of fracture
- Osteoporosis prophylaxis is recommended if the T-score is –1.5 or less, based on the evidence that fractures occur at a higher BMD in corticosteroid-induced osteoporosis than in postmenopausal osteoporosis.
Referring men and premenopausal women
- All men and premenopausal women should be investigated for secondary causes of osteoporosis (for example hypogonadism) if they are found to have osteoporosis; this is usually done by a specialist.
- See the CKS topic on Osteoporosis - treatment for more information on secondary causes of osteoporosis.
© NHS Institute for Innovation and Improvement