Prevention of Steroid-Induced Osteoporosis (BSH 2019)


Note: These notes come from the BSH good practice paper linked to above. This was written specifically for steroid use in ITP. I would have thought it should make us think about osteoporosis in many of our other patients (e.g. A 70kg patient would receive >2g prednisolone after 6x R-CHOP)


Most gen med guidelines recognize a daily oral dose of >5-7.5mg prednisolone for more than three months as conferring an increased risk of osteoporosis.

Adults >40 receiving high dose intermittent steroids (at least one daily dose of >15mg for a short duration) are at risk when the cumulative dose exceeds 1g. (Source: UK GP Database)

A cumulative dose >5g associated with a relative risk increase of 14.4 for fragility fracture.


Consider treatment without additional assessment if:

  • Age >70

  • Men >50 or women post-menopausal who have had a previous fragility fracture


Assess risk with the FRAX score at treatment onset if:

  • Age 40-69 without previous fragility fracture

  • Then, if scored as intermediate risk and steroid course expected to be >12 weeks in length, perform DXA scan and add femoral neck bone mineral density to the FRAX calculator.


Risk assessment not routinely required for:

  • Adults with a low risk FRAX score (before or after DXA)

  • Adults <40 and children


Interventions for all adults starting steroids:

  • Life style advice to optimize bone health

  • Check calcium and vitamin D levels

  • Adequate daily vitamin D (800 iu) and calcium (700-1200mg) intake (diet or supplements)


Additional interventions for adults considered high-risk (see above):

  • Consider oral alendronate or risedronate

  • If contraindicated or poorly tolerated —> zolendronic acid, denosumab or teriparatide