“I’ve fractured my spine from almost nothing — and I’ve been on steroids for my arthritis for years. Could the tablets have caused it?”

A LOW-TRAUMA (fragility) fracture — from standing height or less — is itself diagnostic of OSTEOPOROSIS and a strong marker of high future fracture risk, and a vertebral fragility fracture is significant. Long-term/high-dose oral GLUCOCORTICOIDS markedly increase fracture risk rapidly (often before DEXA changes), causing GLUCOCORTICOID-INDUCED OSTEOPOROSIS — so bone protection should ideally have been started with the steroid (NOGG: prednisolone 7.5 mg or more daily for 3 months or more), and steroids are very likely a major contributor here, which should be acknowledged honestly. Assess fracture risk (FRAX ± DEXA), but in a patient on long-term steroids with a fragility fracture START bone protection now — a BISPHOSPHONATE (e.g. alendronate) with calcium/vitamin D — without waiting for DXA, because a fragility fracture on long-term steroids is itself a treatment indication; check calcium, vitamin D, renal function and dental health first; counsel bisphosphonate administration (upright, with water, before food, oesophageal cautions) and monitoring. Review the glucocorticoid (lowest effective dose, planned taper where possible, steroid-sparing agents/rheumatology review) to reduce ongoing bone and other harm — never stopping it abruptly, and issuing a steroid emergency card (NatPSA/2020/005). Address falls risk (assessment/prevention), lifestyle (weight-bearing exercise, smoking, alcohol, adequate calcium/vitamin D) and fracture care (analgesia, mobilisation, physiotherapy), and check for other causes of vertebral fracture — NICE NG12 1.10.4 myeloma tests at 60 and over with unexplained fracture or back pain (FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis, serum free light chains), metastasis if red flags — with a cord-compression safety-net. Communicate honestly and openly (a candour-style, non-defensive acknowledgement that steroids contributed and bone protection is now needed) without blame, apologising appropriately if protection was missed, and focus on putting it right with future bone monitoring. NICE NG12 myeloma testing (1.10.4) applies at her age with an unexplained fracture.