Long-Term Steroids and Bone Density Testing in Ajax

Why would a pill prescribed for your lungs, joints or bowel lead to a referral for a bone scan? It is a fair question, and one that many people in Ajax only think to ask when a requisition for a bone mineral density test lands in their hands. The medicine is doing an important job, often controlling a condition that would otherwise be painful or dangerous. The bones were not part of the original conversation.

This article explains the connection. It covers how steroid medicines can affect the skeleton, which kinds of steroid usually prompt the discussion, why a bone density scan is only one piece of the assessment, and what is worth bringing to your appointment. It is general information. Your prescriber and family doctor know your history and are the right people to decide what testing and treatment you need.

Please do not stop, reduce or skip a steroid medicine on your own because of anything you read here. After regular use, the body can come to rely on the medication, and stopping suddenly can be dangerous. Any change should be planned with the person who prescribed it.

The kind of steroid this is about

The word “steroid” covers several unrelated groups of medicines, which causes plenty of confusion.

The ones linked to bone loss are glucocorticoids, sometimes called corticosteroids. Prednisone is the best-known tablet. Others include prednisolone, dexamethasone, methylprednisolone and hydrocortisone. They calm inflammation and quiet an overactive immune system, which is why they are used for so many different conditions.

These are not the same as anabolic steroids, the muscle-building hormones that sometimes make the news in sport. They are also different from the hormones in birth control or menopause therapy.

Glucocorticoids come in many forms:

• tablets or liquids taken by mouth
• injections into a vein or muscle
• injections into a joint or soft tissue
• inhalers and nasal sprays
• creams, ointments and eye drops

Most of what is known about bone effects comes from tablets taken over months or years, because that is where the whole-body dose is highest. Inhaled and topical forms are designed to act mainly where they are applied, so at usual doses they generally reach the rest of the body in much smaller amounts. If you use high doses of an inhaled steroid for a long time, or you have had many injections, it is reasonable to ask your health-care provider whether that changes anything for your bones.

How these medicines affect bone

Bone is living tissue that is constantly being rebuilt. Some cells clear away old bone and others lay down new bone, and in healthy adults the two processes stay roughly in balance.

Glucocorticoids tip that balance in a few ways at once:

1. They slow the bone-building cells. Less new bone is laid down to replace what is removed.
2. They can speed up bone breakdown, particularly in the early months of treatment.
3. They reduce how much calcium the gut absorbs and increase how much the kidneys let go.
4. They can weaken muscles, especially around the hips and thighs, which may make falls more likely.

The bones most affected tend to be the ones made largely of spongy inner bone, such as the vertebrae of the spine. That is one reason compression fractures of the spine come up so often in discussions about steroid use.

The amount of risk generally relates to how much is taken and for how long. Many guidelines pay particular attention to people taking tablets for about three months or longer, but your provider will look at your whole pattern of use, including repeated shorter courses over the years.

Conditions that often involve long courses

People are prescribed long-term or repeated steroids for a wide range of reasons. Some of the more familiar include:

• rheumatoid arthritis, lupus and other inflammatory joint or connective tissue conditions
• polymyalgia rheumatica and certain types of blood vessel inflammation
• severe asthma or chronic obstructive pulmonary disease (COPD) with frequent flare-ups
• Crohn’s disease and ulcerative colitis
• some skin, kidney and nerve conditions
• after an organ transplant

Several of these conditions can affect bone in their own right, through inflammation, reduced activity or changes in diet and absorption. So the steroid is often one of a few factors working together, which is part of why an individual assessment matters.

Why the scan is only part of the picture

A bone mineral density (BMD) scan measures how much mineral is packed into specific bones, usually the lower spine and hip. Our bone mineral density service uses a low-energy X-ray technique, and the scan itself is painless.

With steroid use there is an important wrinkle. Steroids affect not just how much bone there is, but also its internal structure and quality. As a result, fracture risk can rise sooner than the density numbers alone might suggest. This is why health-care providers rarely look at a BMD result in isolation for someone on long-term steroids. They combine it with other information, such as age, sex, previous fractures, family history and the steroid itself.

Many Canadian reports include a fracture risk estimate that takes steroid use into account. If you want to understand the numbers on your report, including T-scores, Z-scores and the ten-year risk estimate, our guide to reading bone density results walks through them. For a general overview of who is commonly referred, see who should get a bone density test.

When the conversation tends to come up

There is no single moment that suits everyone, and your provider will decide whether and when testing makes sense. In practice, the subject often arises:

• when a long course of steroid tablets is started or expected
• a few months into treatment, once it is clear the medicine will be needed for a while
• when someone has had several short courses over a year or two
• after a fracture from a minor fall or strain while on, or after, steroid therapy
• when steroids are being tapered or stopped, to understand where bone health stands

If you have been on steroids for some time and nobody has mentioned bones, it is entirely appropriate to bring it up yourself. A simple “Should we be thinking about my bone health with this medication?” opens the door.

Getting ready for your BMD appointment

A physician’s referral is required for a bone density scan. Beyond the usual preparation, people taking steroids can make the visit more useful by bringing some extra information.

The usual preparation

• Bring your health card and requisition.
• Wear clothing without zippers, buckles or metal fasteners if you can.
• Do not take calcium supplements or iron tablets on the day of the exam until after your scan.
• Take your steroid and other prescribed medicines as usual unless your prescriber has told you otherwise. The calcium and iron instruction does not apply to them.

If you manage several medications around the scan, our article on medications and imaging preparation has more detail.

The extra information that helps

Consider writing a short summary before you come:

1. Your steroid history. Name of the medicine, roughly when you started, approximate dose and any periods off it. Include past courses, not only the current one.
2. Other bone-related medicines. Anything prescribed specifically to protect bone, plus any vitamin D or calcium you take.
3. Previous bone density scans. Where and roughly when they were done. Comparing like with like makes follow-up results more meaningful.
4. Any fractures since adulthood, especially from a fall from standing height or less.
5. Changes in height. If you have noticed you are shorter than you used to be, mention it.

The technologist does not interpret results, but having this information on hand helps when you speak with your doctor afterwards.

Changes worth reporting promptly

Some signs suggest a possible fracture or a change in bone health and are worth raising with your health-care provider rather than waiting for a routine visit:

• new back pain that started after a minor strain, cough, lift or bump
• a noticeable loss of height or a change in posture
• a fracture from a fall that would not normally break a bone

If you have a fall with severe pain and cannot bear weight, or back pain with new numbness, weakness in the legs, or loss of bladder or bowel control, call 911 or go to the nearest emergency department. A community imaging clinic is not set up for emergencies.

Questions to take to your prescriber

You might find it helpful to ask:

• How long am I likely to need this medicine?
• Does my dose or the way I take it affect my bones?
• Would a bone density scan be useful now, or later?
• Is there anything you would like me to do to protect my bones while I am on it?
• If I need a follow-up scan, when should it be done?

Answers will differ from person to person, and that is how it should be. Some people need closer monitoring, while others may need very little beyond the usual healthy habits.

Bone density scans close to home

Rossland Diagnostic Clinic provides bone mineral density testing at Unit 102, 300 Rossland Road East in Ajax, a short drive for patients across Pickering, Whitby and the rest of Durham Region. There is free parking and ground-floor access, which can make a difference if a condition or medication has left you feeling unsteady. If you have a requisition, call us at 905-426-3111 or request an appointment online, and we will find a time that works for you.