Glucocorticoid-induced bone loss is fastest in the first six to twelve months, which is exactly the period in which the decision usually gets deferred to the next appointment. By the time a DXA is arranged and reviewed, much of the loss has happened.
A workable rule for clinic: if you expect the patient to be on prednisolone 5 mg or more for three months or longer, make the bone decision now. Take a fracture history, measure height, ask about previous fragility fracture and parental hip fracture, and check calcium and vitamin D status. Older patients, those with a prior fragility fracture and those on higher doses do not need a DXA before starting protection — the risk is already clear enough.
Write the intended steroid duration in the notes when you prescribe. It is the single piece of information the next clinician needs to judge whether protection is still warranted, and it is almost never recorded.
- Prednisolone 5 mg or more expected for 3 months or longer: make the bone decision at prescription
- Prior fragility fracture or advanced age justifies starting protection without waiting for DXA
- Check and correct calcium and vitamin D in everyone — deficiency is common in Indian patients
- Record the intended duration of glucocorticoid in the notes, not just the dose
- Reassess when the dose changes; protection is not a decision made once
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