Steroids and osteoporosis are definitely linked. A type of osteoporosis, resulting from long-term steroid use, is a secondary osteoporosis referred to as steroid induced osteoporosis. I have seen steroid use stated as either the second or third leading cause of osteoporosis in the USA. Either way, this is significant, and something everyone taking steroids should be made aware of. Steroids, specifically glucocorticoids, are drugs commonly used to treat many types of inflammatory diseases, such as asthma and the autoimmune diseases (such as lupus, Crohn's disease, multiple sclerosis and rheumatoid arthritis).
In discussing the relationship between steroids and osteoporosis, we need to talk about glucocorticoids. Glucocorticoids are steroidal hormones that are naturally produced in the human body. One of the most important glucocorticoids, Cortisol (also known as hydrocortisonewhen used topically), is made in the adrenal glands. While it has a number of physiological roles in the human body, one of its most important roles is suppressing inflammation. Inflammation is an immune response by the body, where it releases white blood cells (which serve to defend the body against both infectious disease and foreign materials) in an attempt to heal itself. This process results in inflammation at the site of injury or infection. Cortisol helps to suppress the body's immune response by reducing the inflammatory response.
In autoimmune diseases, the body's immune system gets out of control. Your immune system is designed to protect your body from invaders, such as viruses and bacteria. In an autoimmune disease (or autoimmune disorder), your immune system gets confused and attacks your own cells, mistaking them for invaders. Drug companies have been able to synthesize a whole range of glucocorticoid drugs which can be given to try and control inflammation resulting from these diseases. These drugs may be given orally, topically or by injection.
One of the more important glucocorticoids in relationship to steroids and osteoporosis is Prednisone (which is taken orally) - it is used to treat a whole range of inflammatory diseases. Glucocorticoids are very powerful drugs and are very effective in treating acute issues. However, long-term use of these drugs can have very serious side effects, one of the most serious being osteoporosis.
The scientific evidence is overwhelming that steroid induced osteoporosis is a very real danger. I found numerous studies clearly pointing to a strong relationship between patients on glucocorticoids and a significant loss of bone mineral density, often resulting in osteoporosis. Most worrisome is the indication that this loss of bone mineral density is swift and significant in patients on these drugs. I have seen estimates of up to 15% of bone mass being lost within the first few months of steroid treatment, with a continued annual loss of around 2% (1). Even small doses, less than 7.5 mg of Prednisone per day, can result in significant bone loss (2). The message is clear that an individual's osteoporosis risk factors greatly increase when on glucocorticoid steroids.
I first realized how great this effect of steroids on bone health was when I was caring for a 40-year-old man with Wegener's disease (an autoimmune disease that causes inflammation of the blood vessels). Wegener's disease requires long-term steroids to suppress the immune system. This patient had been on steroids about a year when he was admitted again to my nursing unit. I was surprised to see him again, because his symptoms seemed under control. Well, then he told me he was being admitted to have hip replacement surgery - both of his hips had lost so much bone that he needed total replacement. Only a year on steroids and he had advanced osteoporosis. Scary!
Steroids, like Prednisone, can affect bone physiology in two very significant ways. First, they interfere with the osteoblasts (cells that form new bone) and second, they inhibit osteoclasts (cells that break down bone). In a nutshell, these steroids not only prevent new bone from forming, but accelerate the breakdown of existing bone tissue.
There is no doubt that long-term steroid used to treat chronic illness will eventually result in osteoporosis. One of the most distressing issues for me, and something I found cited often in my research, is the lack of concern or awareness given to this issue. Very few healthcare providers educate their patients about the link between use of steroids and osteoporosis. Most patients are simply not given the appropriate information or provided with guidelines to help minimize the inevitable loss of bone mass they will face when on corticosteroids. From personal experience working in a hospital with patients on long-term steroids, I can tell you this is true. What is going on here? One study clearly found that primary care physicians of patients being treated with steroids were not evaluating these patients for osteoporosis, especially when these patients did not have any other osteoporosis risk factors (3).
Not only should patients be clearly advised of the link between steroids and osteoporosis, they should be put on a program to minimize steroid induced osteoporosis. First, every patient should have a bone mineral density test (refer to my page on osteoporosis t score) before beginning long-term steroid treatment. A baseline can then be established in which to measure the degree of bone loss that patient encounters during treatment. Every patient should then be put on supplements for osteoporosis, such as calcium and Vitamin D. Patients are sometimes administered bisphosphonate drugs to help minimize bone loss. However, bisphosphonates have their own side effects and I belive people taking these potent drugs should be well-advised of these side effects. Patients should also be educated about exercise for osteoporosis prevention, and be advised to follow a diet for osteoporosis prevention. Finally, they should limit or eliminate any habits which also contribute to osteoporosis, such as excessive caffeine consumption or smoking (see my pages on caffeine and osteoporosis and smoking and osteoporosis).
Sometimes it is necessary to take steroids in order to stay alive. While it is wonderful we have available to us these life-saving drugs, it is vital that everyone on such drugs be educated about the side effects. Yes, there is definitely a link between steroids and osteoporosis, but for the patient on these drugs, an osteoporosis prevention program, including supplements for osteoporosis, healthy exercise and following healthy eating guidelines can mean the difference between being diagnosed with advanced osteoporosis and not!
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Osteoporosis T Score - Everything You Need To Know About This Osteoporosis Test.
Smoking and Osteoporosis- Does Smoking Affect Your Bone Mineral Density?
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Caffeine and Osteoporosis - Does Drinking Coffee Put You At Risk For Osteoporosis?