Steroid-induced Osteoporosis

Ewa Sewerynek; Michal Stuss


Aging Health. 2012;8(5):471-477. 

In This Article

Fracture Risks

A direct correlation has been found between daily dose of steroids and the risk of fractures, which rises after 3–6 months of therapy and decreasing after treatment cessation.[18] Risk of fracture is increased for all osteoporotic fracture types and in all age groups, including young people. It also depends on BMD, sex and prevalent fractures.[4,19] In addition, it is well known that up to 50% of patients treated with steroids experience asymptomatic fractures after 3 months of therapy.[19,20] In a meta-analysis involving 42,000 women and men, it was found that glucocorticoids decreased BMD, which was associated with an increased risk of fractures, particularly of the hip. In addition, fracture risk was higher in younger patients than in postmenopausal women and had no associations with previous fractures.[19]

Fracture risk increases even with small doses of steroids between 2.5 and 7.5 mg. Moreover, the duration of treatment and cumulative doses are also important.[21,22] According to van Staa et al., the risk of fractures rises even when using steroids in doses of less than 2.5 mg of prednisolone or daily equivalent.[21] Data from an evaluation of 244,325 women treated with glucocorticoids were compared with data of a matched control group. The relative fracture risks during the first year of therapy were 1.77 (95% CI: 1.55–2.02) and 2.27 (95% CI: 1.94–2.66) for patients taking prednisolone in doses of 2.5–7.5 mg and 7.5 mg daily, respectively.[21]

It was demonstrated in another epidemiological study that, in a group of patients treated with systemic glucocorticosteroids, the risk of vertebral fractures significantly increased (twofold for the hip and the forearm) compared with untreated controls.[23] In patients receiving 10 mg of prednisolone (or its equivalent) daily for 3 months, the risk of hip fractures increased sevenfold and the risk of lumbar spine fractures increased by 17-fold.[24] In light of these data, it is still not known which steroid doses are safe for the skeleton. Arbitrarily, it has been decided that the use of steroids for at least 3 months is assumed to be a clinically significant risk factor for osteoporosis and this value has thus been adopted in 10-year fracture risk calculators.[25–29] It is worth mentioning that certain diseases for which steroid therapy is used, significantly increase the risk of osteoporosis themselves, including asthma, inflammatory bowel diseases, post-transplantation status and rheumatoid arthritis.[30–33]

Locally-applied (topical, inhaled) steroids do not seem to increase fracture risk, except when administered in regular doses ≥7.5 mg/day of prednisolone (1875 µg of budesonide or beclomethasone).[34] It has, however, been demonstrated that BMD is lower in both situations: chronic application of inhaled steroids with intermediate doses of oral steroids and also when they are taken continuously in a combined form of therapy.[35–37] According to the dose of steroids, patients with asthma can be divided into three groups: low, medium and high risk of osteoporosis.[38] The low-risk group includes patients taking beclomethasone in doses ≤800 µg/day in adults or ≤400 µg/day in children. The medium risk group includes patients receiving inhaled steroids in doses >800 µg/day in adults or >400 µg/day of beclomethasone in children. Patients at high risk of developing osteoporosis take systemic steroids at least four times a year. The last group also includes patients receiving combined therapy of inhaled, topical and oral steroids.[38]