Glucocorticoid-induced bone loss is fastest in the first months of treatment, so bone protection belongs at the start of a long-term course, not after a DXA scan or a fracture. Waiting misses the window when most bone is lost.
For anyone starting prednisolone at around 5–7.5 mg/day or more for an expected three months or longer, assess fracture risk and start calcium and vitamin D, adding a bisphosphonate (or an alternative such as denosumab) in those at moderate-to-high risk from the outset. Reassess as the dose tapers, and use the lowest steroid dose for the shortest time in parallel.
This is established practice that is still widely omitted, and it sits naturally alongside the day's reminder that cumulative steroid exposure, not just the current dose, is what drives harm.
- Begin bone protection when long-term steroids start, not after a scan or a fracture.
- Give calcium and vitamin D to all, and add a bone-protecting agent in those at moderate-to-high fracture risk from the outset.
- Trigger at roughly prednisolone ≥5–7.5 mg/day for ≥3 months, and reassess as the dose falls.
- Pair it with using the lowest effective steroid dose for the shortest time.
Why it matters
Most glucocorticoid bone loss happens early, so delayed protection misses the period that matters most.
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