What pharmacological options are available for the management of corticosteroid-induced osteoporosis, and when should they be initiated?

Pharmacological options for managing corticosteroid-induced osteoporosis include bisphosphonates and denosumab. Bisphosphonates are commonly used to reduce fracture risk in patients on long-term corticosteroid therapy. Denosumab may also be considered, particularly in cases where bisphosphonates are contraindicated or not tolerated.

Initiation of pharmacological treatment should be considered early in patients starting long-term corticosteroids, especially if they are at increased risk of fracture. Risk assessment using tools such as FRAX or QFracture should be performed to estimate 10-year fracture risk, taking into account corticosteroid use as a major risk factor.

Specifically, treatment is generally recommended for people who are starting or continuing systemic glucocorticoids at a dose equivalent to 7.5 mg or more of prednisolone daily for 3 months or longer, particularly if they have additional risk factors such as age over 65, previous fragility fracture, or other causes of secondary osteoporosis.

Calcium and vitamin D supplementation should also be considered alongside pharmacological treatment to support bone health.

Regular monitoring and reassessment of fracture risk should guide ongoing management.

These recommendations align with NICE guidance on osteoporosis risk assessment and management in people on corticosteroids ¹.