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Angry relative of cancer patient

A There is a linear relationship between steroid exposure and bone density so any amount of steroid, even inhaled, causes some reduction. My advice is first to use measures to limit the dose of steroid such as long-acting ß2 agonists.

Lifestyle options which are good for bones should be encouraged: regular weight-bearing exercise, restricting alcohol to two units/day and quitting smoking. A good intake of calcium is important; 1g/day if premenopausal, 1.5g if postmenopausal.

The National Osteoporosis Society produces a useful booklet with calcium content of common foods. Some patients need supplements. Good vitamin D levels are also important. A surprising number of adults with chronic health problems are short of vitamin D so check if in doubt. In the over-70s I give supplements anyway.

If a patient is only on inhaled steroids the above is sufficient. If they have courses of oral prednisolone what you do depends on their age and the amount of steroid they are getting. In premenopausal women bone density seems to recover between courses of steroids so bisphosphonates are unnecessary.

In postmenopausal women if the average dose is >5mg/day for three months and they are over 65 or have previously had a fragility fracture, bisphosphonates should be considered. Between 50 and 65 guidelines suggest a DEXA scan and starting bisphosphonates if the T score is <-1.5. don't="" forget="" men="" get="" steroid-related="" osteoporosis="">

Dr Theresa Allain is

consultant geriatrician at Southmead Hospital, Bristol

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