Fractures in adults on systemic steroid therapy: which prophylaxis?

(1) Systemic steroid therapy leads to a loss of bone density after a few months. The loss is at least partly reversible on treatment cessation. Together with age, the underlying disease, and reduced mobility, systemic steroid therapy is a risk factor for fractures. (2) There are no treatments with proven efficacy in the prevention of fractures among patients on systemic steroid therapy. Prevention is thus based on restricting steroid therapy to situations where the benefits are likely to outweigh the risks. (3) The first preventive measure is to encourage adequate calcium intake, as for all subjects at risk of osteoporosis. There is no firm evidence that all patients on steroids require medicinal calcium supplementation. (4) Some treatments slow the decline in bone density associated with steroid therapy, but none has a demonstrated preventive effect on symptomatic fractures. This is the case of the calcium + vitamin D combination, which has the best risk-benefit ratio. Two diphosphonates and, in postmenopausal women, hormone replacement therapy, also have a positive effect on bone density.