Does taking cortisone long-term weaken your bones?

Yes, taking cortisone long-term weakens your bones. With prolonged use, up to 50% of patients face an increased risk of vertebral fractures. The effect works in two directions: the cells that build new bone are suppressed, while the cells that break bone down become more active. This has been recognised for decades as one of the most serious side effects of long-term corticosteroid therapy.

Cortisone also disrupts calcium balance. Your intestines absorb less calcium from food, and your kidneys let more calcium wash out through urine. In response, your body produces more parathyroid hormone, and that hormone further accelerates bone breakdown.

Not everyone faces the same level of risk. People who have taken more than 10 grams of cortisone in total, are older than 50, or already had low bone density before treatment are the most vulnerable. Smoking, excessive alcohol use, low levels of physical activity, and low sex hormone production increase the risk further. Notably, in cortisone-related bone loss, fractures occur mainly in the spine and ribs rather than the hip, which distinguishes it from other forms of osteoporosis.

There are medications that can slow bone loss. Bisphosphonates are the best supported for both prevention and treatment. Calcitonin (nasal spray) and active vitamin D can improve bone density in the spine, but the evidence for this is less robust. Calcium and vitamin D alone are insufficient. They work best as a supplement to other medications.

An important caveat: although bisphosphonates and other medications measurably improve bone density, studies to date have not shown that they also reduce the number of actual fractures in people who use cortisone long-term. Whether improved bone density truly translates to fewer fractures has therefore not yet been proven in this specific context.