Read this bit first. Do not stop, reduce, or change a prescribed medication because of something you read in this newsletter. Not one of the drugs below is a bad drug. All of them are crucial for maintenance of a healthy body in one way or another if they’ve been prescribed by a Doctor.
This article is for information only and for you to potentially have a discussion with your doctor, please do not skip any doses.
Many of the women I speak to who have an osteoporosis or osteopenia diagnosis, have never been told about what medications they’ve been prescribed is doing to their bone density and quality.
But they have been told to get their calcium and vitamin D supplements in, with a brief understanding of K2.
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Send this to one woman who’s been told her bones are “just ageing.” That’s how this list grows, one reader who needed it, passing it to the next.
This is the biggy.
In a study of roughly 250,000 UK primary care patients, people taking more than 7.5mg of prednisolone daily had a relative risk of vertebral fracture of 5.18 compared with non-users.
Not 5% higher but five times, this is a huge increase in risk.
That’s van Staa and colleagues, published in 2000. Twenty-six years old, replicated many times over, and still not reaching the people it’s about.
Two more things from that same work, and they’re the ones that matter clinically.
It’s dose-dependent, between 2.5 and 7.5mg a day, relative risk of vertebral fracture was 2.59. Even below 2.5mg a day it was 1.55. At all doses of glucocorticoids there is a higher relative risk of fracture in comparison to people not taking them at all.
The changes happen rapidly, starting within months of taking the medication, not years, and it falls back down to baseline when stopping. Glucocorticoids suppress bone cells, reducing the amount of new and healthy bone tissue being formed.
The study covered men and women, of all ages. It isn’t just a study of postmenopausal women. Just because the stated increase is 5.18 times higher than baseline population, it shows the shape of the risk, not your specific number.
This one is unresolved, there is no hard yes or no.
A meta-analysis of 24 observational studies covering 2.1 million people found PPI use associated with hip fracture at a relative risk of about 1.20. Modest, but real, and it’s been the basis of a lot of alarming internet content.
Here’s what almost never gets quoted alongside it. The Women’s Health Initiative followed 161,806 postmenopausal women. In fully adjusted models, PPI use showed no association with hip fracture at all. Other fracture sites did show a signal. The hip didn’t.
That’s the largest, best-matched dataset we have for the population reading this, and it disagrees with the observational estimate. Which is what usually happens when a modest association gets properly adjusted for everything else going on in people who need long-term reflux medication.
So I’m uncertain they have a huge effect, but it is worth knowing about, and definitely not a reason to come off omeprazole. What it is worth doing is asking whether you still need it. Long-term PPI prescriptions have a habit of outliving the problem that started them.
Across 16 studies, users showed a fracture relative risk of around 1.61 compared with non-users. There’s a plausible mechanism, since serotonin receptors sit on the cells that build and break down bone.
However, depression itself affects activity, nutrition and falls, and people on antidepressants differ from people who aren’t in ways no statistical adjustment fully catches.
I’d file this as a real association with an uncertain cause. It is nowhere near a reason to stop treating depression.
This is the one I’d most want a woman over 50 to know about, because it’s the most fixable (and it affects my Mum).
The correct amount of levothyroxine does not affect bone density. However, a dose that is too high for a woman’s needs, that pushes TSH down below normal range can affect bone density.
Abrahamsen and colleagues tracked this properly in 2015. For each additional six-month period spent with a suppressed TSH, the risk of major osteoporotic fracture rose. In their age and sex-stratified analysis, cumulative time spent over-replaced predicted fracture specifically in postmenopausal women.
So monitoring your symptoms through your GP or Doctor is important, as a prolonged period of time having low TSH will build and build.
It isn’t a list of drugs to be frightened of, every one of these medications exist because not having them was worse.
The person on prednisolone for giant cell arteritis is taking it to keep her sight. The risk calculation there isn’t close, and no bone health argument beats it.
These medications have a known effect on bone, that effect is manageable, as long as you work with your Doctor to make sure the dosages are correct for what you’re needing.
Take these to your next review. Write them down beforehand, because you won’t remember in the room.
1. “Given how long I’ve been on this, does my bone health need assessing?”
For long-term oral steroids the answer is usually yes and there are established guidelines for it. For the others it’s a judgement call, but somebody should be making that judgement rather than skipping past it.
2. “Am I still on the lowest dose that works, and is this still the right drug for me?”
It’s especially worth asking about levothyroxine, and PPIs.
There’s no exercise program that cancels a drug effect.
But you’re not choosing between a medication and your bones. You’re choosing what else goes alongside the medication. Resistance training builds the muscle that pulls on bone, and it keeps you steady enough to catch yourself, which matters when the bone underneath is more fragile. Two women on the same prednisolone dose, one strong and one deconditioned, are not carrying the same fracture risk.
Your health is multi-faceted and exercise, although it is high effort, is more often than not going to improve your health and quality of life.
Make the right decision and start pushing yourself.
If you know someone who’s been on long-term steroids, or who’s been on the same levothyroxine dose for a decade without a recent TSH check, forward this to them. It’s a five-minute read that might change one conversation with their GP, and that’s the whole point of it
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