Oral Steroids Quickly Increase Your Risk of Fracture
June 7, 2000 -- People with asthma are frequently prescribed oral steroids,
but a new study suggests that even three months of relatively low dose
treatment can increase the risk of fracture by 70% -- a much faster rate of
"bone-wasting" than experts previously predicted.
The good news, however, is that the study also suggests that when the drugs
are stopped, the risk decreases with similar speed. This quickness is very
surprising, C. Conrad Johnston, MD, an expert on osteoporosis, tells WebMD.
Johnston, who is a professor of medicine at Indiana University School of
Medicine in Indianapolis, was not associated with the study.
The drugs associated with this increased risk -- oral corticosteroids -- are
prescribed for a number of inflammatory conditions, such as asthma, joint
disorders, and inflammatory bowel disorder. Johnston says that the link between
steroid use and fracture has been known for many years, but most experts
believed that the adverse effect was not evident until after prolonged use.
This new finding questions that belief, he says.
The researchers analyzed medical records from nearly 250,000 people who were
taking oral steroids to the same number of healthy non-users who were the same
age and sex. The team of researchers from England, Canada, and the Netherlands
followed the users of oral steroids for the entire time they were taking the
drugs and for about three months after they received their last
In the study, which was published in the Journal of Bone and Mineral
Research, the researchers report that the steroid users had 20 fractures
for every 1,000 people per year, compared to 13 fractures for every 1,000
people for the control group.
There are other factors that can increase fracture risk, such as illness or
other drugs, but the researchers write that even after accounting for those
other risks, the rate of fractures "was significantly higher among oral
corticosteroid users." They also found that when the dose of the oral
steroid was increased, the fracture rate also increased.
The results of this study suggest that when a physician prescribes an oral
steroid he or she should also prescribe a bisphosphonate such as Fosamax ,
which is used for treatment of osteoporosis, says Stavros C. Manolagas, MD,
PhD, professor of medicine and director of the center for osteoporosis and
metabolic bone disease at the University of Arkansas. Bisphosphonates have been
shown to help counteract the loss of bone mineral density that is associated
with steroids, he says. "It makes perfect sense to start [bisphosphonates]
immediately; there is no reason to wait for months," Manolagas says.
However, Johnston says the jury is still out on the need to prescribe
bisphosphonates for everyone taking steroids because "everybody doesn't get
The authors of the study, as well as Johnston and Manolagas, say the most
puzzling aspect of the new finding is the speed at which the fracture risk
increases. Manolagas tells WebMD that three months is too short a time for bone
mineral density to significantly decrease. In his editorial, he suggests that
the steroids may kill osteocytes, the most common type of bone cells. This cell
death, called apoptosis, may increase the fracture risk, he says.
Johnston says that Manolagas may be on the right track but he says he doubts
that the cell death theory can explain "the finding that fracture risk can
change so quickly." He says the answer may lie not in total bone mineral
density loss but "in where you lose it and the site at which it is