Preventing Steroid-induced Osteoporosis

One of the side-effects of taking steroid tablets in the long term is an increased risk of developing osteoporosis (thinning of your bones). This is known as steroid-induced osteoporosis. Using a high-dose steroid inhaler in the long term may also be a risk. Various things can be done to reduce your risk of developing steroid-induced osteoporosis. These include lifestyle measures such as stopping smoking, reducing your alcohol intake and increasing your exercise levels. You should also make
sure that you have adequate amounts of calcium and vitamin D and sometimes supplement tablets may be needed. Medicines to prevent steroid-induced osteoporosis may also be prescribed for some people. Note: never stop or reduce your steroid treatment unless your doctor tells you to do so.

Why are steroid medicines taken?

Steroids may be taken to treat many different conditions. They work mainly by reducing inflammation and so are used to treat various conditions where inflammation occurs. For example: some autoimmune diseases; some types of muscle, skin, and joint diseases; asthma, etc. Steroids are also used to treat some cancers. The outlook (prognosis) for a number of diseases has improved, sometimes dramatically, since steroids became available.

Steroid medicines are sometimes called cortisone or corticosteroids. They can be taken in many ways. For example, as tablets by mouth, via inhalers to deliver steroid into your lungs, or by creams to rub on to your skin. Long-term steroid medication is needed to treat some conditions and keep symptoms under control. Unfortunately, this long-term treatment can have side-effects. There is often a balance between the risk of side-effects against the symptoms and damage that may result from some diseases if they are not treated with steroids. Note: long-term treatment with low-dose steroid inhalers or steroid skin creams does not carry the same risk of serious side-effects as long-term treatment with steroids.

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.

What can be done to prevent steroid-induced osteoporosis?

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. There are some simple exercises that you can do at home.

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.
Take the minimum dose of steroids possible for the shortest period of time

In general, the higher the dose of steroid tablets taken in the long term, the higher your risk of developing a fragility fracture. However, saying that, there is not really a safe dose of steroid tablets because even low doses can increase your fracture risk. Talk to your doctor about the dose of steroid tablets that you are taking. Could the amount of steroid be reduced? Is there another way that the steroid medication may be taken rather than as tablets by mouth? For example, steroids applied to the skin or inhaled into the lungs may be possible to treat some conditions. Taking the steroid medication in another way may help to reduce the effect of the steroids on your bones.

How long a course of steroid tablets do you need? You should also discuss this with your doctor. The course of treatment should be as short as possible. However, as mentioned already above, there is often a balance between the risk of side-effects from taking steroid tablets against the symptoms and damage that may result from some diseases if they are not treated with steroids.

Testosterone for Osteoporosis

Men can take testosterone by:

    Receiving a shot into the muscle (intramuscular injection, or IM) every 2 to 3 weeks.
    Using an adhesive patch (transdermal) that is applied to the skin every night. Two types of patches can be used:
        Testoderm, which is applied to the scrotum.
        Androderm, which is applied to other areas of a man's body, such as his back, upper arms, abdomen, or thighs.
    Rubbing a gel (AndroGel) on the shoulders, upper arms, or abdomen once a day.

Men who have low naturally occurring testosterone take testosterone medicine to bring their levels back to normal. This slows bone thinning and reduces calcium loss.

Testosterone is used to prevent osteoporosis in men who have low testosterone levels. Testosterone is not used to prevent or treat osteoporosis in women.

Testosterone may improve bone thickness, especially in the bones of the spine (vertebrae), but the evidence is not clear.1

Many men with low testosterone levels report that they feel better and have increased energy while taking testosterone.

Side effects of testosterone include:

    An elevated number of red blood cells (polycythemia), which can increase the risk of stroke or heart attack.
    Swelling in the hands and feet.
    Increase in size of the prostate gland (hyperplasia).
    Enlargement of the breasts (gynecomastia). This is rare.
    Painful erections (rare).
    Problems with the function of the liver (rare).

The most common side effect of using the adhesive patch (transdermal) testosterone is redness and itching at the application sites.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

Testosterone should not be used if you are taking the supplement dehydroepiandrosterone (DHEA). DHEA is a human steroid hormone that decreases with age. It frequently is advertised as a "rejuvenation" supplement. DHEA may increase testosterone levels, and the combination of the two therapies may be dangerous. Too much testosterone may cause seizures, hepatitis, problems with blood clot formation, or other serious health problems.

Many other supplements may interact with testosterone. Be sure to tell your doctor about any nonprescription medicines, supplements, or herbs you are taking.

Older adult men with low testosterone levels are twice as likely to break a hip as men with normal testosterone levels.

Testosterone is not used to treat osteoporosis in women.

Testosterone should not be taken by men who have prostate cancer. 

Hormone Effective for Steroid-Induced Osteoporosis

The synthetic parathyroid hormone teriparatide is an effective treatment for glucocorticoid-induced osteoporosis, a form of bone loss seen in patients treated with steroids, according to a study funded by the manufacturer.

Patients with glucocorticoid-induced osteoporosis who took teriparatide for 36 months had greater increases in bone mineral density and fewer vertebral fractures than those treated with alendronate, a bisphosphonate osteoporosis drug sold as Fosamax, an online article in Arthritis & Rheumatism reported.

Subjects at high risk of fracture associated with sustained glucocorticoid use who received teriparatide had significantly greater increases in spine and hip BMD compared with subjects receiving alendronate during the 36 months of therapy.

Patients with glucocorticoid-induced osteoporosis treated with teriparatide also experienced significantly fewer new vertebral fractures, most occurring during the first 18 months, with no significant difference between groups in the incidence of nonvertebral fractures."

Glucocorticoids are used to control inflammation in patients with autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, and Crohn's disease, as well as inflammatory conditions such as asthma.

However, long-term use of glucocorticoids such as prednisone, prednisolone, dexamethasone, and cortisone can result in reduced bone mass and strength, increasing fracture risk.

In the new study, participants were randomly assigned to receive injectable teriparatide (20 µg/day) plus oral placebo (150 subjects) or oral alendronate (10 mg/day) plus injectable placebo (144 subjects). They were also given supplements of calcium and vitamin D.

In addition to seeing greater improvements in bone mineral density and fewer vertebral fractures, subjects who took teriparatide saw significant increases in levels of biomarkers of bone turnover, including N-terminal type I procollagen propeptide (PINP), osteocalcin (OC) and C-terminal telopeptide of type I collagen (CTX).

More patients who took teriparatide (21%) had elevated predose serum calcium concentrations compared with those in the alendronate group (7%)"Our data indicated that teriparatide is efficacious and generally well tolerated for treating subjects with glucocorticoid-induced [osteoporosis] and should be considered as a therapeutic option for subjects at high risk of fracture," the authors concluded.

They noted that the study had a high dropout rate, with 44% of patients leaving during the three years, which might have reflected the severity of the disorders being treated and the propensity for the patients to have other diseases. However, there was no difference in dropout rates between the two study groups.

Preventing Steroid-induced Osteoporosis

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.

Osteoporosis in Men

Osteoporosis is a disease that causes the skeleton to weaken and the bones to break. It poses a significant threat to millions of men in the United States.

Osteoporosis is called a “silent disease” because it progresses without symptoms until a fracture occurs. It develops less often in men than in women because men have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss. However, in the past few years the problem of osteoporosis in men has been recognized as an important public health issue, particularly in light of estimates that the number of men above the age of 70 will continue to increase as life expectancy continues to rise.

How Is Osteoporosis Diagnosed in Men?

Osteoporosis can be effectively treated if it is detected before significant bone loss has occurred. A medical workup to diagnose osteoporosis will include a complete medical history, x rays, and urine and blood tests. The doctor may also order a bone mineral density test. This test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a dual-energy x-ray absorptiometry, or DXA test. It is painless a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

It is increasingly common for women to be diagnosed with osteoporosis or low bone mass using a BMD test, often at midlife when doctors begin to watch for signs of bone loss. In men, however, the diagnosis is often not made until a fracture occurs or a man complains of back pain and sees his doctor. This makes it especially important for men to inform their doctors about risk factors for developing osteoporosis, loss of height or change in posture, a fracture, or sudden back pain.

Some doctors may be unsure how to interpret the results of a BMD test in men, because it is not known whether the World Health Organization guidelines used to diagnose osteoporosis or low bone mass in women are also appropriate for men. Although controversial, the International Society for Clinical Densitometry recommends using separate guidelines when interpreting BMD test results in men.

What Treatments Are Available?

Once a man has been diagnosed with osteoporosis, his doctor may prescribe one of the medications approved by the FDA for this disease. The treatment plan will also likely include the nutrition, exercise, and lifestyle guidelines for preventing bone loss listed at the end of this fact sheet.

If bone loss is due to glucocorticoid use, the doctor may prescribe a medication approved to prevent or treat glucocorticoid-induced osteoporosis, monitor bone density and testosterone levels, and suggest using the minimum effective dose of glucocorticoid.

Other possible prevention or treatment approaches include calcium and/or vitamin D supplements and regular physical activity.

If osteoporosis is the result of another condition (such as testosterone deficiency) or exposure to certain other medications, the doctor may prescribe several anabolic steroids. Anabolic steroids are largely used in treatment of testosterone deficiency and are used as a part of testosterone replacement therapy. Thus anabolic steroids had a positive exposure in osteoporosis treatment.

Benefits Of Kefir

Kefir is a fermented milk drink containing beneficial bacteria helping not only to lose weight but also to normalize microflora of bowels. Benefits of kefir were described in ancient tractates. Modern medicine defines ten its important features:

1. Kefir helps to regulate work of our bowel. It is most beneficial for children who carried intestinal infections. Kefir restores normal microflora of bowels in disbacteriosis and dysbiosis helping to normalization of biochemical reactions and physiological function of the body.

2. Kefir is a “live product”. It contains fermented milk bifidus bacteria inhibiting growth and development of disease-causing and putrifactive microorganisms. So, in one – two weeks of regular kefir consumption in urine disappear phenolic articulatings.

3. Kefir makes antibiotics consumption more safe by minimizing antibiotics negative effects on bowels bacteria.

4. Kefir provides our body with all necessary nutrient materials and biologically active elements (vitamins, aminoacids, peptides, etc).

5. Kefir helps to prevent coprostasia and colitis.

6. Kefir lowers cholesterol rate in the blood.

7. Kefor prevents from cancerous growths of large bowel and rectum.

8. Kefir stimulates immune system which helps to allergic reactions reduction.

9. Kefir is a source of protein and calcium which assist to strengthening of bones and children growth. Calcium from kefir is digested more better than from milk. Therefore, kefir may be a perfect preventive measure against osteoporosis which frequently becomes cause of traumas in older people.

10. Milk is digested during an hour by 32%, but kefir during the same time is digested completely.