Patients who have commitment or exposure to oral glucocorticoids for greater than three months (or treated for combined total of three months a year e.g. COPD patients) at any dose.

If a patient has an eGFR less than 30mL/min, do not treat without appropriate specialist advice, refer to renal team if patient not already known to them

Aged 65 years or older or

Aged less than 65 years and has a definite history of previous fragility fracture:

• Treat
  • Calcium plus vitamin D and either alendronic acid 70mg weekly or risedronate 35mg weekly
  • For more information and second-line treatments see 6.6 Drugs affecting bone metabolism
• Lifestyle advice (see below)
• Once the patient completely stops the corticosteroid, consider a DXA scan to guide whether bisphosphonates should be discontinued

Aged less than 65 years, no history of previous fragility fracture:

• Perform DXA scan:
  • T score equal to or greater than -1.5, treat as above
  • T score less than -1.5, consider treating with calcium and vitamin D whilst on steroids unless confident patient is replete
• Lifestyle advice (see below)
• Consider further scan in a minimum of 2 years if patient remains on corticosteroids

Lifestyle advice

• Weight bearing exercise, 20 minutes three times a week
• Healthy balanced diet. Encourage calcium rich foods if not taking calcium and vitamin D
• Stop smoking
• Sensible alcohol consumption, maximum 2 units daily for women or 3 units for men
• Daylight exposure, face and arms for 20 minutes daily three times a week.