Glucocorticoid induced osteoporosis

How much prednisolone is considered too much for bone?

  • As low as 2.5 mg of prednisolone !
  • Generally, 5-7.5 mg/day of prednisolone (or equivalent) for >3 months

FRAX score

  • See this link:
  • Calculator that calculates your patient’s 10 year absolute risk of osteoporotic and hip fracture.


Problem with this is:

  • Glucocorticoid therapy is a categorical variable—a yes-or-no question—and yes is defined as having ever used a
    glucocorticoid in a dose greater than 5 mg for
    more than 3 months.
  • A patient taking 5 mg of prednisolone has the same risk of a patient taking 50 mg of prednisolone.
  • Therefore, in the ACR guideline, they create a risk strata for glucocorticoid induced osteoporotic fracture.

ACR risk strata for glucocorticoid induced osteoporotic fracture


For pre-menopausal women with non-childbearing potential

  • >5 mg/day for >1 month: alendronate/risedronate
  • >7.5 mg/day for >1 month: above or zoledronic acid
  • any dose >3 months: teriparatide

For pre-menopausal women with childbearing potential

  • Treatment is recommended only when prednisolone >7.5 mg/day for >3 months.

Other recommendations



Comparing to NICE guideline:

  • FRAX score is used as the risk assessment calculator.
    – In contrast to ACR, they didn’t differentiate treatment based on the doses and duration of treatment.
    – Adjustment on FRAX score can be done on the dosage of corticosteroids (Kanis et al,2010)
  • High risk: treatment
    – Alendronate & risedronate
    – Consider specialist referral for people who cannot take or tolerate alendronate or risedronate.
    – No mention of zoledronic acid
  • Intermediate risk: DEXA scan and recalculate the FRAX score
  • Low risk: lifestyle advice

** The adjustment based on glucocorticoid dosage:

  • < 2.5 mg daily of prednisolone or equivalent): probability decreases by 20%
  • 2.5-7.5 mg daily, the unadjusted FRAX value can be used.
  • > 7.5 mg daily, probability increases by 15%.

Remember the rule of ~20%
– <2.5 mg/day: risk decreases by 20%
– 2.5-7.5 mg/day: unadjusted FRAX score
– >7.5 mg/day: risk increases by 20%

3 things to remember

  1. Glucorticoid >5 mg/day for >3 months = high risk for glucocorticoid induced osteoporosis.
  2. Use FRAX score. Adjust the score based on glucocorticoid dosage by Kanis et al or use ACR guideline.
  3. Treat if high risk; BMD assessment and recalculate if intermediate; lifestyle advice if low risk.


CHAD L. DEAL, MD. Recent recommendations on steroid-induced osteoporosis: More targeted, but more complicated. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 2 FEBRUARY 2013

Kanis et al. Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int. 2011 Mar;22(3):809-16





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