Medical Treatments: Strengthening and Protecting Steroid-Treated Bone

When you are taking steroids long-term, lifestyle changes are rarely enough to protect your bones on their own. For most people at moderate to high risk, specialized medications are needed to counteract the “double hit” of steroids increasing bone breakdown and stopping bone formation ^[1][2].

The American College of Rheumatology (ACR) updated its guidelines in 2022 to emphasize early, proactive treatment. If you are taking at least 2.5 mg of prednisone daily and expect to be on it for more than 3 months, your doctor will use your DXA results, fracture history, and FRAX score to place you into a risk category ^[1].

Medication Classes and Priorities

There are three main types of medication used to protect your bones from steroids. Your risk category, along with shared decision-making regarding kidney function and personal preferences, determines which one your doctor might recommend ^[1].

• Bisphosphonates: These are major recommended options for many patients. They work by slowing down the cells that break down bone. They can be taken as a weekly or monthly pill (like alendronate) or a once-yearly IV infusion (like zoledronic acid) ^[1][3]. They require adequate kidney function.
• PTH/PTHrP Agents (Anabolics): Medications like teriparatide (Forteo) actually stimulate your body to build new bone. The ACR conditionally recommends these as initial therapy for adults at high or very high risk because they have been shown to reduce vertebral fractures in steroid users. However, oral or IV bisphosphonates and denosumab remain alternatives ^[1][4].
• Denosumab (Prolia): This is an injection given every six months. It is a powerful “antiresorptive” that stops bone breakdown. It is an effective option for GIOP and is sometimes selected if you have severe kidney disease, but it requires a very specific long-term plan ^[1][5]. Hypocalcemia must be corrected before starting.

The Importance of ‘Sequential Therapy’

Unlike many medications, you cannot simply stop certain bone treatments when you feel better. This is known as sequential therapy—using one drug to “lock in” the gains of another ^[6].

• After Anabolics: Once you finish a course of a bone-builder (usually 18–24 months), you generally must follow it with an antiresorptive (like a bisphosphonate or denosumab). Without this follow-up, the new bone your body built may be lost ^[7][6].
• The Denosumab Warning: This is critical. Denosumab should not be stopped or substantially delayed without a clinician-arranged antiresorptive transition. If you stop denosumab without starting another medication, your bone turnover can “rebound” to dangerously high levels, significantly increasing your risk of multiple spinal fractures in a short period ^[8][9].

Understanding Rare Side Effects in Context

Many patients worry about two rare side effects associated with bisphosphonates and denosumab: Osteonecrosis of the Jaw (ONJ) (delayed healing of the jawbone) and Atypical Femoral Fractures (AFF) (stress fractures in the thigh bone) ^[10][11].

To make an informed decision, it is helpful to look at the absolute risk:

• ONJ Risk: In patients treated for osteoporosis (rather than cancer), the risk is extremely low—estimated at about 0.04% (or roughly 1 in 2,500 people) ^[12]. It is most often linked to invasive dental work like extractions ^[13]. You should complete routine dental care, but do not independently stop your medication for dental work.
• AFF Risk: These are also very rare and usually only seen after many years of continuous treatment ^[14].
• The Comparison: Your own fracture risk must be compared with the risk of each medication. For a high-risk patient on steroids, the absolute risk of a debilitating spinal fracture generally outweighs the risk of these rare side effects ^[15][16].

Duration and ‘Drug Holidays’

A “drug holiday” is a planned break from a bisphosphonate to reduce the risk of long-term side effects. However, the rules for these holidays are different when you are on steroids:

• Standard Rule: For non-steroid users, a holiday might be considered after several years of treatment if their risk has become low ^[14].
• The GIOP Exception: Continuing glucocorticoids increases concern, but does not automatically make every patient high risk. If you are still taking steroids, your risk often remains elevated, and your clinician will reassess your fracture risk to determine if a holiday is appropriate or if treatment should continue ^[17][18].

Always discuss any planned changes in your bone medication with your care team to ensure your “exit strategy” is safe.