Steroids and Bone Loss: Glucocorticoid-Induced Osteoporosis Explained

Do steroids cause bone loss and osteoporosis?

Long-term oral steroids (glucocorticoids) such as prednisolone can cause bone loss — and peer-reviewed reviews describe glucocorticoid-induced osteoporosis as the most common secondary, medication-related cause of osteoporosis. A 2018 review in Endocrine identified it as the most common secondary cause of the condition Endocrine, 2018, and the Endotext clinical reference similarly calls it the most common cause of iatrogenic (treatment-related) osteoporosis Endotext / MDText.com, Inc., 2019.

That does not mean everyone on a steroid develops osteoporosis. It means the link is well established enough that UK and international guidance treats steroid use as a major risk factor worth assessing — which is why understanding what causes osteoporosis matters if you have been prescribed one. If you take a steroid, speak to your GP or prescriber about your own risk before you stop or change anything.

How do steroids weaken bone?

Steroids tip the normal balance of bone turnover towards breakdown. According to the Royal Osteoporosis Society, glucocorticoids activate the cells that break bone down, slow the cells that build new bone, reduce how much calcium the body absorbs, and affect sex hormones that help keep bone strong Royal Osteoporosis Society, 2024.

The result is a skeleton that loses tissue faster than it can replace it. That combination — more breakdown, less building — is what makes steroid-related bone loss distinct from the slow, age-related decline most people experience, and why it can show up relatively early in a course of treatment.

How quickly do steroids affect bone?

Faster than ordinary age-related loss — steroid-related bone loss is at its fastest in the first months. Reviews describe a biphasic pattern: rapid loss in the first several months to a year, followed by a slower, continuing decline Cleveland Clinic Journal of Medicine, 2020. Fracture risk climbs on a similar timeline, rising within three to six months of starting oral steroids in a dose-dependent way Endocrine, 2018.

Crucially, the risk can rise before large density changes are obvious — steroid-related fractures can happen even when a bone-density scan hasn't yet dropped into the osteoporosis range. Because of that early, front-loaded risk, NOGG advises that bone-protective treatment can begin alongside glucocorticoids in higher-risk patients without waiting for a bone density scan National Osteoporosis Guideline Group (NOGG), 2024.

How much steroid, and for how long, raises the risk?

Both the dose and how long you take it matter — and risk can rise even at fairly low doses. The Cleveland Clinic Journal of Medicine notes that relative fracture risk goes up even at doses as low as 2.5 mg of prednisolone a day, and that prevention or treatment should be considered for anyone taking the equivalent of 2.5 mg or more per day for three months or longer Cleveland Clinic Journal of Medicine, 2020. The Royal Osteoporosis Society similarly flags that risk is highest with high doses, with steroid tablets, and with use for longer than three months Royal Osteoporosis Society, 2024.

Higher doses raise the stakes further. NOGG links prednisolone doses of 7.5 mg a day or more over three months — in groups such as postmenopausal women and men aged 50 and over — to starting bone protection earlier, particularly where there is a prior fragility fracture or a fracture-risk score above intervention thresholds National Osteoporosis Guideline Group (NOGG), 2024. None of this is a reason to reduce a dose yourself: prescribers aim to use the lowest effective dose for the shortest necessary time precisely to limit these effects.

What does UK guidance recommend if you're on steroids?

Broadly, UK guidance recommends assessing fracture risk and considering bone protection for people on longer-term oral steroids — with the specifics decided by your clinician. The Royal Osteoporosis Society advises that bone health should be discussed when a steroid is first prescribed Royal Osteoporosis Society, 2024. NOGG sets out that bone loss and fracture risk increase rapidly with oral glucocorticoids and with dose, and that treatment can start alongside the steroid in higher-risk patients rather than waiting for a scan National Osteoporosis Guideline Group (NOGG), 2024.

Part of that process is estimating your overall fracture risk, often using a tool like FRAX — our guide to fracture risk and FRAX explains how that works. This article deliberately does not name specific drugs, doses or treatment plans, because those decisions belong with the clinician who knows your full history.

Are inhaled steroids as risky as steroid tablets?

Generally no — inhaled steroids are considered less likely to cause bone loss than steroid tablets. The Royal Osteoporosis Society notes that most experts regard inhalers as less likely to harm bone than tablets, and that it is oral steroids taken for more than three months that carry the clearest risk Royal Osteoporosis Society, 2024. The Endotext review reaches the same conclusion — inhaled steroids tend to be better for bone than oral or systemic steroids — while cautioning that they are not entirely without effect Endotext / MDText.com, Inc., 2019.

The practical message is one of proportion, not alarm: if you use a steroid inhaler for asthma or COPD, the bone risk is generally far lower than for someone on long-term prednisolone tablets. As always, never stop a prescribed inhaler or tablet without medical advice.

Why get a bone-health baseline if you're on steroids?

Because steroid-related bone loss can happen early and fracture risk can rise before big density changes appear, knowing your starting point helps you and your clinician act sooner. A bone density scan measures bone density, which the Royal Osteoporosis Society describes as one factor in overall bone strength — considered alongside things like age and family history — and scans can be repeated (typically every two to five years) to monitor bone strength and reassess whether treatment would help Royal Osteoporosis Society, 2024.

That monitoring role is where a radiation-free approach fits. A REMS scan is one way to establish a baseline and track change over time without the X-ray dose of a standard DEXA — useful when the goal is to keep an eye on things across a course of steroid treatment. It complements, rather than replaces, your GP's or specialist's fracture-risk assessment and any bone-protection decisions. If you are weighing up NHS options too, our guide to a bone density scan on the NHS sets out how referral usually works, and you can read more about our own bone health assessment.

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This article is part of our bone health series. To understand the bigger picture, see our guide to what causes osteoporosis.