Prednisolone therapy (corticosteroid therapy)

It is well known that long-term use of oral corticosteroid type medications such as prednisolone, cortisone, hydrocortisone and dexamethasone can adversely affect bone and lead to osteoporosis.⁵⁵

These medications are prescribed for a variety of conditions such as chronic airways disease, asthma, rheumatoid arthritis, inflammatory bowel disease, certain skin conditions, inflammatory conditions such as polymyalgia rheumatica etc.

As a general rule long-term treatment, that is more than 2 months in duration with doses of more than 5 – 7.5 mg of prednisolone per day (or equivalent doses of hydrocortisone 2 mg per day or dexamethasone 50 mg per day) increase the risk of osteoporosis.^56-58 In addition, if other risk factors for osteoporosis, such as being postmenopausal are present, then the effects of corticosteroid medication on the bones can be severe.⁵⁹

As the effects of corticosteroid medication can rapidly lead to bone loss and subsequent fracture whilst on these therapies, it is important for women to consider having a review by their doctor. There are now recognised therapies (bisphosphonates eg Fosamax, Actonel, Didrocal), which can be used to try and offset the rate of bone loss whilst having corticosteroid therapy.^60-63 Studies looking at giving bisphosphonates for corticosteroid-induced osteoporosis, recommend that they be used when the bone density measures less than a T score of -1.0 on a DEXA scan⁶⁴ (refer to interpretation of DEXA scan). However, in the absence of a low trauma fracture, these treatments are not yet subsidised by PBS.

As of November 2003, Actonel has received RPBS (for veterans) listing for the treatment of corticosteroid-induced osteoporosis. In this setting there does not need to be a history of an osteoporosis (low trauma) related fracture. However, the individual must satisfy certain criteria, which include:

• Prednisolone therapy of 7.5 mg daily (or an equivalent)
• On corticosteroid therapy for at least 3 months
• Documented bone mineral density of a T score of less than -1.0 (less than minus 1.0)

Adrenal Insufficiency (Addison’s disease)/ Hypopituitarism

Women (and men) with Addison’s disease (deficient in cortisol) or hypopituitarism (pituitary gland failure) require long-term physiological replacement of cortisol with corticosteroid drugs (e.g. cortisone, hydrocortisone, prednisolone). There is increasing evidence that the replacement doses of cortisol used in these conditions can lead to osteoporosis. Usually, this is in the setting of over-replacement with these medications^65-68 or when there are other co-existing risk factors for osteoporosis. Hence, it is important for women to discuss with their doctor whether they need to have a bone check if they have these conditions.

Rheumatoid Arthritis

Rheumatoid arthritis is a condition, which affects approximately 1% of the population with women affected approximately three times more than men. It is a condition that usually develops between the ages of 25 to 50, but is not uncommon in the elderly.

Rheumatoid arthritis not only leads to joint damage, but it also leads to osteoporosis, especially in the bone adjacent to the affected joints. If prednisolone is prescribed as part of the medical treatment, this can also lead to the development of osteoporosis.⁶⁹

Women with rheumatoid arthritis or any other connective tissue disease such as lupus, scleroderma etc, need to discuss the issue of having an assessment for osteoporosis with their treating doctor.

Thyroxine (Oroxine) Treatment / Hyperthyroidism (Overactive thyroid)

It is recognised that conditions such as Graves’ disease or toxic multinodular goitre, which result in an overactive thyroid (too much thyroid hormone production) can lead to osteoporosis. Usually this occurs when the disease is active and the amount of thyroid hormone production is excessive.^70,71 The adverse effects on bone usually subside when the condition is treated and the amount of thyroid hormone produced from the thyroid gland normalizes.

There has also been concern about the risk of over replacement with thyroxine (oroxine) hormone. Sometimes this is done as part of routine treatment for thyroid cancer and multinodular goitre (benign, non-toxic). Some studies have suggested that over replacement with this hormone may decrease bone mass,⁷² especially if other risk factors for osteoporosis are present such as menopause.⁷¹ However one study has not shown an increased risk of osteoporosis in this setting, provided that the over replacement with thyroxine is not too excessive.⁷³ Hence, if women are at all concerned about the effects of over replacement with thyroxine (oroxine), it is recommended that they discuss this with their treating doctor.

Content updated February 20, 2006