When you're on long-term corticosteroids-whether for lupus, rheumatoid arthritis, asthma, or another chronic condition-you're not just managing one disease. You're also quietly fighting another: osteoporosis. This isn't a slow, inevitable side effect. It happens fast. Within just three to six months of starting daily steroids like prednisone, your bone density can drop by 5-15%. Your fracture risk? It doubles or even triples. And here's the worst part: most people don't even know it's happening until they break a bone.
Why Steroids Eat Your Bones
Corticosteroids don't just calm inflammation. They mess with your bones at the cellular level. They shut down the cells that build bone (osteoblasts), speed up the cells that break it down (osteoclasts), and reduce your body’s ability to absorb calcium from food. Your kidneys also start flushing out more calcium instead of keeping it. All of this adds up to rapid bone loss, especially in the spine and hips-areas that take the most impact in daily life.The numbers are brutal. For every extra milligram of prednisone you take daily, you lose about 1.4% of bone density in your spine each year. At 7.5 mg or more per day, your fracture risk doubles. And it doesn’t matter if you’re young or active. Even people who exercise regularly and eat well can lose bone mass on steroids. The reason? Steroids blunt the natural bone-building response to weight-bearing activity by about 25%.
Who’s at Risk-and How Fast?
You’re in the danger zone if you’re taking 2.5 mg or more of prednisone daily for three months or longer. That’s the threshold the Royal Osteoporosis Society and the American College of Rheumatology both use to define high-risk patients. But here’s what no one tells you: the biggest damage happens in the first year. Half of all steroid-related fractures occur within 12 months of starting treatment.Women are more likely to be screened and treated-but men are just as vulnerable. Studies show only 44% of men on long-term steroids get any bone health intervention, compared to 76% of women. That gap is dangerous. Men often assume osteoporosis is a "women’s issue," but steroid-induced bone loss doesn’t care about gender.
The Foundation: Calcium and Vitamin D
You can’t fix steroid-induced bone loss without fixing your calcium and vitamin D levels. This isn’t optional. It’s the bare minimum. The Cleveland Clinic recommends 1,000-1,200 mg of calcium daily and 600-1,000 IU of vitamin D. Ideally, get calcium from food-yogurt, cheese, fortified plant milks, leafy greens, sardines-but most people need supplements to hit the target.Vitamin D is even more critical. Your body needs it to absorb calcium. Many people on steroids are deficient, even in sunny places like Brighton. Studies show that taking 1,000 IU of vitamin D daily can cut annual bone loss in the spine by more than half compared to placebo. One study found that patients on low-dose steroids who took calcium and vitamin D lost only 0.72% of bone density per year-while those who didn’t lost 2%.
Movement Matters-But Not All Exercise Is Equal
You’ve heard "exercise is good for bones." But on steroids, that advice isn’t enough. Walking alone won’t cut it. You need weight-bearing and resistance training-activities that put stress on your bones to trigger rebuilding.Try:
- Brisk walking or stair climbing for 30 minutes most days
- Bodyweight squats, lunges, or wall push-ups
- Light dumbbell or resistance band workouts twice a week
- Balance exercises like standing on one foot (to prevent falls)
Don’t skip this. Research shows that people who stick to these routines while on steroids lose less bone than those who don’t-even if their BMD still drops a little. The goal isn’t to reverse the damage overnight. It’s to slow it down and prevent fractures.
Quit Smoking. Cut Back on Alcohol.
If you smoke, you’re already at higher risk for bone loss. Steroids make it worse. Quitting smoking can reduce your fracture risk by 25-30%. That’s as powerful as some medications.Alcohol? Limit it to three units per day. More than that interferes with bone formation and increases fall risk. One glass of wine isn’t the problem. Daily binge drinking is.
When Medication Is Necessary
Calcium and vitamin D aren’t enough for everyone. If you’re on steroids long-term, have a history of fractures, or your bone density test shows osteoporosis (T-score ≤ -2.5), you need stronger treatment.Bisphosphonates like risedronate or alendronate are the first-line drugs. Risedronate cuts vertebral fractures by 70% in steroid users. It’s taken as a daily or weekly pill. But side effects-like heartburn or stomach upset-mean about 30% of people stop taking it.
If bisphosphonates don’t work for you, there are other options:
- Zoledronic acid: A yearly IV infusion. Boosts spine BMD by 4.5% in a year.
- Denosumab: A shot every six months. Increases spine BMD by 7% in 12 months.
- Teriparatide: A daily injection. The most powerful option. Increases spine BMD by 9.1% in a year-more than double the gain of bisphosphonates. Recommended for severe cases or people who’ve already broken a bone.
Teriparatide isn’t for everyone. It’s expensive, requires daily shots, and is usually limited to two years of use. But for high-risk patients, it’s the most effective tool we have.
Testing Is Not Optional
You can’t manage what you don’t measure. A DXA scan (bone density test) should happen at the start of steroid therapy-and again every 1-2 years if you’re still on it. Don’t wait for pain. Don’t wait for a fall. By the time you feel it, it’s too late.Doctors should also use FRAX, a tool that estimates your 10-year fracture risk based on age, sex, steroid dose, and other factors. On steroids, your risk is equivalent to someone 10-15 years older. That’s not a suggestion. That’s a medical red flag.
Why So Many People Are Still Getting Hurt
Here’s the shocking truth: only about 15% of people on long-term steroids get full, guideline-approved care. That means 85% are flying blind.Why? Because the system is broken. Primary care doctors often don’t know what to do when a rheumatologist prescribes steroids. Patients think bone loss is just "part of the deal." Pharmacies don’t follow up. Electronic records don’t flag high-risk patients automatically.
But there’s hope. One VA hospital system added automatic alerts to their electronic records: when a patient gets a steroid prescription over 2.5 mg/day for 3 months, the system pops up a checklist-"Check BMD? Prescribe calcium? Refer to bone specialist?"-and intervention rates jumped from 40% to 92%.
Pharmacist-led education programs also work. In one UK study, patients who got regular check-ins from a pharmacist about their meds, supplements, and bone health were 2.5 times more likely to stick to their treatment plan.
What You Can Do Today
You don’t have to wait for your doctor to act. Take control:- Ask for a DXA scan if you’ve been on steroids for 3+ months.
- Get your vitamin D level checked. If it’s below 30 ng/mL, start supplementing.
- Track your calcium intake. Use a free app like MyFitnessPal for a week-you’ll be surprised how hard it is to hit 1,200 mg.
- Start a simple home workout: 10 squats, 10 wall push-ups, 5 minutes of heel raises. Do it every morning.
- Call your pharmacy. Ask if they offer free medication reviews. Many do.
And if your doctor dismisses your concerns? Say this: "I’m on steroids long-term. According to the American College of Rheumatology, I need bone density testing and prevention. Can we discuss that?"
It’s Not Too Late
Bone loss from steroids is serious-but it’s not unstoppable. With the right steps, you can stop the damage, rebuild some strength, and avoid fractures. The key is acting early, staying consistent, and refusing to accept bone loss as a given.Steroids saved your life. Now, make sure they don’t break it.
