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Steroid osteoporosis prevention — SCE Rheumatology MCQ

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HardRheumatological pharmacologySteroid osteoporosis preventionSCE Rheumatology

A 63-year-old man has newly diagnosed polymyalgia rheumatica. He has started prednisolone 15 mg daily and is expected to require systemic glucocorticoids for approximately 18 months. He has no previous fragility fracture. FRAX, recalculated with femoral-neck bone mineral density and adjusted for glucocorticoid dose, is above the age-specific UK intervention threshold but below the very-high-risk threshold. Renal function and serum calcium are normal, and he has no oesophageal disorder. What is the most appropriate strategy to prevent glucocorticoid-induced osteoporosis?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Start an oral bisphosphonate now and optimise calcium and vitamin D intake

Explanation lettering: C = shown as A · A = shown as C · E = shown as D · D = shown as E

B is correct. His prolonged systemic glucocorticoid exposure and FRAX probability above the UK intervention threshold warrant prompt pharmacological bone protection despite the absence of a previous fracture. With normal renal function and no oesophageal contraindication, an oral bisphosphonate is an appropriate first-line option; calcium intake and vitamin D status should also be optimised. Lifestyle measures alone are insufficient once the treatment threshold has been crossed, and treatment should not be delayed until the T-score reaches −2.5. First-line anabolic treatment is generally reserved for very-high-risk patients, which he is not. Denosumab may be considered when appropriate, but it is not the default choice here and must not be stopped without planned sequential antiresorptive therapy because of rebound bone loss and vertebral-fracture risk.

Reference: National Osteoporosis Guideline Group. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis. Published 2025. https://pubmed.ncbi.nlm.nih.gov/40921943/