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Corticosteroid Users at Risk

by Cooper B. Wilhelm

Though often effective in treating rheumatoid arthritis (RA), lupus, and ankylosing spondylitis, glucocorticoids have also been linked to an increased risk of low bone density and fracture, and it is generally recommended that people taking glucocorticoids (sometimes called corticosteroids) also take medicine to strengthen their bones. However a recent study found a surprising number of Americans taking these drugs do not.

Your body constantly renews your bones. As certain cells break down old bone, other cells build more. However, glucocorticoids (such as prednisone, methylprednisolone, hydrocortisone, and cortisone) interfere with this process, weakening bones. Glucocorticoids have been shown to increase the rate at which bone is broken down, decrease the rate at which it is rebuilt, inhibit the body's ability to take in calcium from food, and increase the rate at which the body expels calcium. The resulting diminished bone density greatly increases a person's risk of fracture.

According to recommendations issued by the American College of Rheumatology (ACR), people taking glucocorticoids often experience a steep drop in bone mineral density during their first three months on the drugs, and a slower, steady loss as long as they use them. The ACR recommends that people taking glucocorticoids also take drugs to counteract these effects.

Evidence has been building for years, however, that shows many Americans taking glucocorticoids don't take—or even realize they should take — drugs to counteract the effect glucocorticoids have on their bones.

A study recently accepted to Arthritis Care & Research was the first to try to get a sense of the issue using nationally representative data. The results were "troubling."

Looking at almost a decade's worth of data from the National Health and Nutrition Examination Survey, researchers determined that only a little more than a third of people using oral glucocorticoids in the United States (37.9%) also took one of the drugs the researchers identified as decreasing the risk of bone loss.

In particular, researchers highlighted the low use of bisphosphonates. Bisphosphonates are a class of drugs that includes alendronate (brand name Fosamax) and risedronate (brand name Actenol).

"Many studies have suggested that calcium and vitamin D alone are not enough to efficiently reduce the adverse effects of glucocorticoids on bone," Dr. Jun-Yen Yeh, one of the study authors, said in an e-mail. "During the study period (1999-2008), bisphosphonates were the most efficient pharmaceutical options to prevent or treat bone loss due to glucocorticoid use, and should be the only FDA-approved medications for this purpose." However, less than 10% of people taking glucocorticoids were also taking bisphosphonates.

These results were particularly striking given that the risk of bone loss increases the longer a person takes glucocorticoids, and the researchers estimated that on average, people taking glucocorticoids did so for more than four years.

These findings are in line with a those of a study published seven years ago that found that only about 42% of people taking glucocorticoids long term received treatment to counter their effect on bone density or even underwent bone density testing.

This new study is also being published just as the American Society for Bone and Mineral Research's task force is urging assessment and treatment be offered to all people over the age of 50 who have suffered a low-trauma fracture: a first, "sentinel" fracture is often a sign of poor bone health and a precursor to a second, more severe fracture.

Last Reviewed on August 9, 2012

Cooper B. Wilhelm is an Editorial Assistant at Arthritis Self-Management.

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