From the Guidelines
Steroid-induced osteopenia is a significant concern in patients on long-term glucocorticoid therapy, and preventive measures should be taken from the start of treatment to minimize bone loss and reduce the risk of fractures, as recommended by the British Society of Gastroenterology consensus guidelines 1. The effects of steroid-induced osteopenia can be mitigated with calcium and vitamin D supplementation, as well as bisphosphonates for those at higher risk of bone loss.
Key Recommendations
- All patients beginning steroid therapy expected to last more than 3 months should receive calcium (800-1000 mg daily) and vitamin D supplementation (800 IU daily) 1.
- For those at higher risk of bone loss, bisphosphonates like alendronate or risedronate are recommended first-line treatments, with teriparatide considered for severe cases or when bisphosphonates are contraindicated 1.
- Bone mineral density testing should be performed at baseline and monitored every 1-2 years during continued steroid therapy.
- Lifestyle modifications including weight-bearing exercise, smoking cessation, limiting alcohol intake, and using the lowest effective steroid dose are essential components of management.
Mechanism of Bone Loss
Steroids cause bone loss primarily by decreasing bone formation through inhibition of osteoblast function and increasing bone resorption by enhancing osteoclast activity, with most rapid bone loss occurring in the first 6-12 months of therapy 1.
Importance of Early Intervention
Early intervention is critical as bone loss begins quickly after steroid initiation, and preventive therapy should be started concurrently with steroid treatment rather than waiting for osteopenia to develop 1.
Additional Considerations
- Patients on long-term steroids should have a repeat bone densitometry at 1 year, and if stable, repeated at two to three-year intervals, but if declining, repeated annually 1.
- Intravenous zoledronic acid given annually may be used first line where there is evidence of malabsorption or increased risk of gastrointestinal side effect from oral bisphosphonate use 1.
From the FDA Drug Label
Sustained use of glucocorticoids is commonly associated with development of osteoporosis and resulting fractures (especially vertebral, hip, and rib). It occurs both in males and females of all ages. Osteoporosis occurs as a result of inhibited bone formation and increased bone resorption resulting in net bone loss
The effects of steroid-induced osteopenia (bone loss due to glucocorticoid use) include:
- Inhibited bone formation
- Increased bone resorption
- Net bone loss
- Increased risk of fractures, especially vertebral, hip, and rib fractures This occurs in both males and females of all ages due to sustained use of glucocorticoids 2.
From the Research
Effects of Steroid-Induced Osteopenia
The effects of steroid-induced osteopenia, also known as corticosteroid-induced osteoporosis, are significant and can lead to increased risk of bone loss and fractures. Some of the key effects include:
- Decreased bone mineral density, resulting in loss of bone mass and increased risk of fractures 3, 4, 5
- Suppression of osteoblastic activity, leading to decreased bone formation 5
- Increased bone resorption, caused by secondary hyperparathyroidism 6, 7
- Decreased intestinal calcium absorption and increased urinary calcium excretion 6, 7
Risk Factors
Several risk factors can increase the likelihood of developing steroid-induced osteopenia, including:
- Long-term use of corticosteroids, even at low doses 3, 4
- Smoking, excessive alcohol consumption, and lack of exercise 4, 5
- Hypogonadism, menopausal status, and low bone mineral density at baseline 4, 5
- Previous osteoporotic fractures and chronic inflammatory diseases 5
Prevention and Treatment
Prevention and treatment strategies for steroid-induced osteopenia include:
- Calcium and vitamin D supplementation, although the evidence for their effectiveness is limited 3, 4, 6, 7
- Bisphosphonates, which have been shown to be effective in increasing bone density and reducing fracture risk 3, 4
- Hormone replacement therapy, which may be beneficial for postmenopausal women and hypogonadal men 3, 4, 5
- Lifestyle modifications, such as regular exercise, balanced diet, and avoidance of smoking and excessive alcohol consumption 4, 5