If you have inflammatory bowel disease (IBD), your doctor may have prescribed steroids such as prednisone to decrease inflammation during an acute flare-up. The common side effects of steroids range from annoying to debilitating, but most of them will go away when the dosage is tapered down and discontinued. However, steroids can also contribute to the development of potentially serious and permanent effects, especially with high dosages and/or prolonged use. One of these conditions is steroid-induced osteoporosis.
Osteoporosis is a weakening of the bones, which causes them to lose their density and become brittle and more susceptible to fracture. It is largely thought of as a disease of post-menopausal women, which is true in part, but it can happen to men or women of any age who are at risk. Some of the risk factors include:
- Age (over 65)
- Caucasian or Asian descent
- Family history of osteoporosis
- Thin/small build (less than 154 lbs)
- Previous fracture
- Use of certain medications (including steroids and thyroid hormones)
- Early menopause
- Inadequate calcium intake; inadequate vitamin intake
- High-protein diets
- Sedentary lifestyle
- Alcohol abuse
- Parathyroid disease
While steroids do decrease inflammation, they also decrease the formation of new bone, increase the breakdown of old bone, and decrease the absorption of calcium from food by the body. In the case of IBD, the development of osteoporosis may be compounded by the already low amount of calcium absorbed by the body.
Diagnosis of Steroid-Induced Osteoporosis
Osteoporosis is diagnosed with a test called dual-energy x-ray absorptiometry (DEXA). DEXA is more sensitive than a regular x-ray and can find bone loss in its early stages. It is painless and takes about 10 minutes to complete.
The American College of Rheumatology recommends DEXA testing at the start of steroid treatment and periodically (perhaps yearly) thereafter while therapy is continued.
Osteoporosis tends to be more common in people who have Crohn's disease than those who have ulcerative colitis, so a baseline DEXA to catch any early bone loss is recommended for all Crohn's disease patients.
Preventing Steroid-Induced Osteoporosis
Taper steroids: To prevent early bone loss, steroids should only be used in the lowest effectual dosage for the shortest amount of time. Steroid treatment can be extremely useful for many inflammatory conditions, but the benefits should be weighed against the potential for side effects such as osteoporosis. Don't adjust your medication on your own before speaking with your doctor.
Stop smoking: Smoking cigarettes is associated with many of the lifestyle factors that contribute to bone loss, such as poor diet and lack of exercise. Women who smoke may produce less estrogen and experience menopause earlier than women who do not smoke. In addition, smokers take longer to heal from fractures, and tobacco use appears to decrease bone density.
Exercise: Weight-bearing exercise, such as resistance exercise, is helpful in increasing bone mass. Exercise promotes the creation of bone mass and the retention of calcium.
Treating Steroid-Induced Osteoporosis
Supplements: Because calcium is absorbed in the small intestine, malabsorption occurs mainly in people with Crohn's disease who have inflammation in the small intestine. People with ulcerative colitis, which manifests in the large intestine, may have better calcium absorption.
Calcium supplements in the amount of 1500 mg per day may be recommended to treat or prevent early bone loss. Your doctor will need to advise you as to what dosage, if any, is appropriate for you.
It's important to know that calcium doesn't work alone -- it needs vitamin D in order to be absorbed by the body. Vitamin D is synthesized when the skin is exposed to sunlight, but most people do not spend enough time outside to make enough vitamin D. Like calcium, vitamin D is poorly absorbed by people with active inflammation in the small intestine caused by Crohn's disease. Daily supplementation with 400 IU of vitamin D may be recommended to combat early bone loss; again, speak to your doctor about what's advised for you.
Bisphosphonates: Fosamax (alendronate), Actonel (risedronate), Didronel (etidronate), Boniva (ibandronate), and Reclast (zoledronic acid) are bisphosphonates that are used to help bone breakdown and preserve bone mass. These medications may also actually increase bone density in the spine and hip.
Bisphosphonates are currently the only class of drugs that are FDA approved for treating osteoporosis in men. They are typically given with calcium and vitamin D.
Forteo (Teriparatide): Forteo is a parathyroid hormone that is approved to treat steroid-induced osteoporosis; it can be used for up to 2 years. People who have had radiation treatment, such as for cancer, are not good candidates for this drug. Forteo is administered every day by injection.
Calcitonin (Calcimar, Cibacalcin, Miacalcin): Calcitonin helps slow bone loss and prevent fractures in the spine but not in the hip. This medication is administered as a nasal spray and may cause irritation in the nasal passages. It is not as effective for treating steroid-induced osteoporosis, so calcitonin is typically used only in patients who can't take or are intolerant to therapy with bisphosphonates.
Amin S. "Glucocorticoid-Induced Osteoporosis." American College of Rheumatology 2010. 7 Sept 2010.
Rosen HN. "Prevention and treatment of glucocorticoid-induced osteoporosis." UpToDate May 2010. 7 Sept 2010.