What is steroid-induced osteoporosis?
One of the side-effects of taking a steroid medicine in the long term is that it can increase your risk of developing osteoporosis. The steroid lowers your bone density and increases your risk of developing a fragility fracture.
If osteoporosis is thought to be due in part to taking a steroid medicine, it is known as steroid-induced osteoporosis. In fact, the use of steroid medicines is one of the leading causes of osteoporosis. Between 3 and 5 in 10 people who take steroid medicines in the long term will develop a fragility fracture because of osteoporosis if nothing is done to prevent this.
In general, when we are talking about steroid medicines that can cause steroid-induced osteoporosis, we are talking about long-term treatment (for three months or more) with prednisolone tablets. As mentioned above, long-term treatment with steroid creams does not carry the same risks of steroid-induced osteoporosis. However, long-term use of high doses of inhaled steroids may also increase your risk of developing steroid-induced osteoporosis. For this reason, the dose of steroid in an inhaler is usually kept to a minimum so that it is just high enough to keep your asthma or other respiratory problem under control.
Note: if you are taking long-term high-dose steroid inhalers, your should discuss your risks of developing osteoporosis with your doctor. The rest of this leaflet focuses on long-term treatment with steroid tablets.
How do I know if I am at risk of steroid-induced osteoporosis?
If you are taking long-term steroid tablets, your risk of developing steroid-induced osteoporosis can vary depending on your individual situation. For example, your age, your sex, whether or not you have had a previous fragility fracture, or any other risk factors for osteoporosis that you may have.
If you have been taking or buy anabolic steroid tablets for three months or more, or if you are due to start a course of long-term steroid tablets, your doctor may suggest that you have a special scan of your bones, called a DEXA scan. DEXA stands for dual-energy X-ray absorptiometry. It is a scan that uses special X-ray machines to check your bone density and look for any signs of osteoporosis. Bone density is low in osteoporosis. Depending on the results of this scan, and any other risk factors that you may have, your doctor will be able to determine your risk of developing steroid-induced osteoporosis. This will be used to decide if you need treatment with medicines to prevent it (see below).
Certain groups of people may not need to have a DEXA scan before making a decision to start treatment to prevent steroid-induced osteoporosis. For example, older people, or those who have had a previous fragility fracture. This is because their age and/or the fact that they have had a previous fragility fracture puts them at increased risk of having a fragility fracture if they take long-term steroids, no matter what their bone density is.
There are a number of things that can be done to reduce your risk of developing steroid-induced osteoporosis if you are taking steroid tablets for three months or more. These may be things that you can change yourself in terms of your lifestyle, as well as treatment with medicines or other measures that your doctor may suggest.
Stop smoking, limit alcohol intake and exercise more
Certain lifestyle factors (as described in the list above) can increase anyone's risk of developing osteoporosis. If you already have one risk factor for osteoporosis (being on long-term steroid tablets), then it is especially important to try to reduce your number of other risk factors.
Chemicals from tobacco can get into your bloodstream and can affect your bones, making bone loss worse. If you smoke, you should try to make every effort to stop. Also, you should try to cut down on your alcohol intake if you drink more than three to four units of alcohol daily. Separate leaflets called Tips to Help you Stop Smoking and Alcohol and Sensible Drinking give further details.
Exercise can help to prevent osteoporosis. The pulling and tugging on the bones by your muscles during exercise helps to stimulate bone-making cells and strengthens your bones. Regular weight-bearing exercise throughout life is best, but it is never too late to start. This means exercise where your feet and legs bear your body's weight, such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. However, the more vigorous the exercise, the better. For most benefit you should exercise regularly - aiming for at least 30 minutes of moderate exercise or physical activity at least five times per week. Excessive exercise such as marathon running may not be so good. (Note: because swimming is not weight-bearing exercise, this is not so good for preventing osteoporosis.)
Muscle strengthening exercises are also important. They help to give strength to the supporting muscles around bones. This helps to increase tone, improve balance, etc, which may help to prevent you from falling. Examples of muscle strengthening exercises include press-ups and weight lifting but you do not necessarily have to lift weights in a gym.
Ensure an adequate calcium and vitamin D intake
Calcium and vitamin D are important for bone health. Your body needs adequate supplies of vitamin D in order to absorb (take up) the calcium that you eat or drink in your diet. If you are on steroid tablets for three months or more, your risk of steroid-induced osteoporosis can also be reduced by making sure your body has enough calcium and vitamin D.
The recommended daily intake for calcium in adults over the age of 50 is at least 1,000 mg per day. Everyone aged over 50 years should also aim for adequate amounts of vitamin D daily (800 IU). Protein is also important in your diet and one gram a day of protein per kilogram of your bodyweight is recommended. Briefly:
Calcium - you can get 1,000 mg of calcium most easily by:
Drinking a pint of milk a day (this can include semi-skimmed or skimmed milk); PLUS
Eating 50 g (2 oz) hard cheese such as Cheddar or Edam, or one pot of yoghurt (125 g), or 50 g of sardines.
Bread, calcium-fortified soya milk, some vegetables (curly kale, okra, spinach, and watercress) and some fruits (dried apricots, dried figs, and mixed peel) are also good sources of calcium. Butter, cream, and soft cheeses do not contain much calcium.
Vitamin D - there are only a few foods that are a good source of vitamin D. Approximately 115 g (4 oz) of cooked salmon or cooked mackerel provide 400 IU of vitamin D. The same amount of vitamin D can also be obtained from 170 g (6 oz) of tuna fish or 80 g (3 oz) of sardines (both canned in oil). Vitamin D is also made by your body after exposure to the sun. The ultraviolet rays in sunshine trigger your skin to make vitamin D.
Unless your doctor is sure that you have an adequate intake of calcium and have enough vitamin D, they may prescribe calcium and vitamin D supplements if you are taking long-term steroid tablets. If you are unsure about whether you should have calcium or vitamin D supplements, ask your practice nurse or GP.
One of the side-effects of taking a steroid medicine in the long term is that it can increase your risk of developing osteoporosis. The steroid lowers your bone density and increases your risk of developing a fragility fracture.
If osteoporosis is thought to be due in part to taking a steroid medicine, it is known as steroid-induced osteoporosis. In fact, the use of steroid medicines is one of the leading causes of osteoporosis. Between 3 and 5 in 10 people who take steroid medicines in the long term will develop a fragility fracture because of osteoporosis if nothing is done to prevent this.
In general, when we are talking about steroid medicines that can cause steroid-induced osteoporosis, we are talking about long-term treatment (for three months or more) with prednisolone tablets. As mentioned above, long-term treatment with steroid creams does not carry the same risks of steroid-induced osteoporosis. However, long-term use of high doses of inhaled steroids may also increase your risk of developing steroid-induced osteoporosis. For this reason, the dose of steroid in an inhaler is usually kept to a minimum so that it is just high enough to keep your asthma or other respiratory problem under control.
Note: if you are taking long-term high-dose steroid inhalers, your should discuss your risks of developing osteoporosis with your doctor. The rest of this leaflet focuses on long-term treatment with steroid tablets.
How do I know if I am at risk of steroid-induced osteoporosis?
If you are taking long-term steroid tablets, your risk of developing steroid-induced osteoporosis can vary depending on your individual situation. For example, your age, your sex, whether or not you have had a previous fragility fracture, or any other risk factors for osteoporosis that you may have.
If you have been taking or buy anabolic steroid tablets for three months or more, or if you are due to start a course of long-term steroid tablets, your doctor may suggest that you have a special scan of your bones, called a DEXA scan. DEXA stands for dual-energy X-ray absorptiometry. It is a scan that uses special X-ray machines to check your bone density and look for any signs of osteoporosis. Bone density is low in osteoporosis. Depending on the results of this scan, and any other risk factors that you may have, your doctor will be able to determine your risk of developing steroid-induced osteoporosis. This will be used to decide if you need treatment with medicines to prevent it (see below).
Certain groups of people may not need to have a DEXA scan before making a decision to start treatment to prevent steroid-induced osteoporosis. For example, older people, or those who have had a previous fragility fracture. This is because their age and/or the fact that they have had a previous fragility fracture puts them at increased risk of having a fragility fracture if they take long-term steroids, no matter what their bone density is.
There are a number of things that can be done to reduce your risk of developing steroid-induced osteoporosis if you are taking steroid tablets for three months or more. These may be things that you can change yourself in terms of your lifestyle, as well as treatment with medicines or other measures that your doctor may suggest.
Stop smoking, limit alcohol intake and exercise more
Certain lifestyle factors (as described in the list above) can increase anyone's risk of developing osteoporosis. If you already have one risk factor for osteoporosis (being on long-term steroid tablets), then it is especially important to try to reduce your number of other risk factors.
Chemicals from tobacco can get into your bloodstream and can affect your bones, making bone loss worse. If you smoke, you should try to make every effort to stop. Also, you should try to cut down on your alcohol intake if you drink more than three to four units of alcohol daily. Separate leaflets called Tips to Help you Stop Smoking and Alcohol and Sensible Drinking give further details.
Exercise can help to prevent osteoporosis. The pulling and tugging on the bones by your muscles during exercise helps to stimulate bone-making cells and strengthens your bones. Regular weight-bearing exercise throughout life is best, but it is never too late to start. This means exercise where your feet and legs bear your body's weight, such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. However, the more vigorous the exercise, the better. For most benefit you should exercise regularly - aiming for at least 30 minutes of moderate exercise or physical activity at least five times per week. Excessive exercise such as marathon running may not be so good. (Note: because swimming is not weight-bearing exercise, this is not so good for preventing osteoporosis.)
Muscle strengthening exercises are also important. They help to give strength to the supporting muscles around bones. This helps to increase tone, improve balance, etc, which may help to prevent you from falling. Examples of muscle strengthening exercises include press-ups and weight lifting but you do not necessarily have to lift weights in a gym.
Ensure an adequate calcium and vitamin D intake
Calcium and vitamin D are important for bone health. Your body needs adequate supplies of vitamin D in order to absorb (take up) the calcium that you eat or drink in your diet. If you are on steroid tablets for three months or more, your risk of steroid-induced osteoporosis can also be reduced by making sure your body has enough calcium and vitamin D.
The recommended daily intake for calcium in adults over the age of 50 is at least 1,000 mg per day. Everyone aged over 50 years should also aim for adequate amounts of vitamin D daily (800 IU). Protein is also important in your diet and one gram a day of protein per kilogram of your bodyweight is recommended. Briefly:
Calcium - you can get 1,000 mg of calcium most easily by:
Drinking a pint of milk a day (this can include semi-skimmed or skimmed milk); PLUS
Eating 50 g (2 oz) hard cheese such as Cheddar or Edam, or one pot of yoghurt (125 g), or 50 g of sardines.
Bread, calcium-fortified soya milk, some vegetables (curly kale, okra, spinach, and watercress) and some fruits (dried apricots, dried figs, and mixed peel) are also good sources of calcium. Butter, cream, and soft cheeses do not contain much calcium.
Vitamin D - there are only a few foods that are a good source of vitamin D. Approximately 115 g (4 oz) of cooked salmon or cooked mackerel provide 400 IU of vitamin D. The same amount of vitamin D can also be obtained from 170 g (6 oz) of tuna fish or 80 g (3 oz) of sardines (both canned in oil). Vitamin D is also made by your body after exposure to the sun. The ultraviolet rays in sunshine trigger your skin to make vitamin D.
Unless your doctor is sure that you have an adequate intake of calcium and have enough vitamin D, they may prescribe calcium and vitamin D supplements if you are taking long-term steroid tablets. If you are unsure about whether you should have calcium or vitamin D supplements, ask your practice nurse or GP.
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