Bone mineral density and the risk of fracture in patients receiving long-term inhaled steroid therapy for asthma

Effects of long-term inhaled corticosteroid treatment on fragility fractures in older women: the Manitoba BMD registry study

The effects of inhaled corticosteroids (ICS) on fracture risk in older women with chronic respiratory diseases are not well established. Our results indicate long-term ICS use in this population does not increase the risk of major osteoporotic fracture. This finding further elucidates the long-term safety of ICS in older women.

INTRODUCTION

Inhaled corticosteroids (ICS) are frequently used in older women with chronic respiratory diseases. There is insufficient evidence regarding the association between long-term ICS use and the risk of fragility fractures in this population.

METHODS

We used linked Manitoba health administrative databases and the provincial bone mineral density (BMD) registry (1996-2013) to identify women ≥ 40 years of age with asthma and/or chronic obstructive pulmonary disease (COPD) within 3 years preceding the baseline BMD test. We followed them until the first major osteoporotic fracture or end of study, whichever came first. ICS use, stratified by exposure tertiles, was measured within the 12-month period following the baseline BMD test (by total days and quantity, primary outcome), and over the entire follow-up period (by medication possession ratio (MPR) and average annual dose, secondary outcome). The hazard ratio of fracture with ICS use was estimated using a Cox proportional hazards model, controlling for baseline determinants of fracture.

RESULTS

Of 6880 older women with asthma (38%) or COPD (62%), 810 (12%) experienced a major osteoporotic fracture over a mean follow-up of 7.7 years (SD = 3.9). ICS use at any tertile was not associated with an increased risk of fracture (dispensed days, p = 0.90; dispensed quantity, p = 0.67). Similarly, ICS use at any tertile during the entire follow-up period was not associated with an increased risk of fracture (MPR, p = 0.62; average annual dose, p = 0.58).

CONCLUSION

Our findings do not support an increased risk of major osteoporotic fracture in older women with chronic respiratory diseases due to long-term ICS use.

Glucocorticoid-induced osteoporosis: an update

Glucocorticoid-induced osteoporosis is the most common secondary cause of osteoporosis and the resulting fractures cause significant morbidity. Following initiation of oral glucocorticoids, rapid bone loss occurs, and fracture risk increases within a few months in a dose-dependent manner. These adverse effects are due to inhibition of bone formation accompanied by an early but transient increase in bone resorption. Multiple mechanisms underlie these changes in bone remodeling; direct effects include upregulation of PPARγR2, increased expression of sclerostin and increased RANKL/OPG ratio, whilst hypogonadism, altered renal and intestinal calcium handling, and reduced production of insulin-like growth factor 1 also contribute. Fracture risk assessment should be performed as soon as possible after glucocorticoids are initiated and bone protective therapy started promptly in individuals at high-risk, with calcium and vitamin D supplements where appropriate. Oral bisphosphonates are currently regarded as first line options on the grounds of their low cost. However, teriparatide has been shown to be superior in its effects on BMD and vertebral fracture risk in glucocorticoid-treated individuals with osteoporosis and should be considered as an alternative first line option in high-risk patients.

Bone safety of low-dose glucocorticoids in rheumatic diseases

Glucocorticoids are widely used internationally for the treatment of inflammatory disease, such as rheumatoid arthritis (RA). Although the benefit of glucocorticoids in RA on both disease activity and severity are well known, there remain unanswered questions about the overall bone safety of chronic low-dose glucocorticoids in RA. Debate exists about the merits of glucocorticoids for bone health on the basis of their benefits in promoting activity and reducing proinflammatory cytokines. Overall current evidence supports the view that bone loss is a disease related both to RA and to glucocorticoid use independently. Calcium and vitamin D, along with prescription antiosteoporosis therapies, particularly bisphosphonates and teriparatide, play an important role in stabilizing bone mineral density and potentially lowering spinal fracture risk at the spine. International guidelines provide pathways for appropriate prevention of glucocorticoid-induced osteoporosis (GIOP). Despite the evidence and these guidelines, many patients do not receive adequate management to prevent GIOP.

Bone mineral density in asthmatic patients on inhaled corticosteroids in a developing country

INTRODUCTION:

Prolonged use of oral corticosteroids is a risk factor for osteoporosis. However, the effect of inhaled corticosteroids (ICS) on bone mineral density (BMD) of asthmatic patients remains controversial.

OBJECTIVES:

We aimed to determine the prevalence of osteopenia and osteoporosis in our patients with asthma receiving ICSs for more than one year compared with patients who did not have asthma and to determine the risk factors for osteopenia and osteoporosis among the asthmatic patients.

METHODS:

This was a cross-sectional study conducted from August 2007 to July 2009. Asthmatic patients aged 18 years and older who had been on ICS for at least one year and a control group of subjects not on ICS were included. BMD was measured using DEXA (dual energy X-ray absorptiometry) scan. The WHO classification of T-scores for osteopenia and osteoporosis were used.

RESULTS:

A total of 143 subjects were recruited (69 asthmatics and 74 control subjects). T-scores of the spine, femur, and hip of the asthmatics vs the control subjects were mean, −0.72 vs −0.57 (P=0.98); median, −0.60 vs −0.80 (P=0.474); and mean, 0.19 vs 0.06 (P=0.275); respectively. T-scores of the spine, femur, and hip showed significant negative correlation with age and significant positive correlation with body mass index (BMI).

CONCLUSION:

The risk factors for osteoporosis and osteopenia among asthmatic patients were older age and lower BMI, but not the cumulative dose of ICS. Asthmatic patients on ICS have no added risk of osteoporosis or osteopenia as compared with non-asthmatic subjects.

Assessment of bone status in inhaled corticosteroid user asthmatic patients with an ultrasound measurement method

BACKGROUND

The effect of inhaled corticosteroid (ICS) on the bone status of asthmatic patients is still uncertain, because it can differ by race and because there have been few cases in Japan. In this study, the bone status of ICS users with asthma was evaluated in an actual clinical setting in Japan.

METHODS

In 7 participating hospitals, ICS users with asthma and control subjects were age- and gender-matched and recruited into this study. To assess bone status, ultrasound measurements of each individual's calcaneus were made using an AOS-100. The ratio of the osteo sono-assessment index (OSI) to the average OSI corrected for age and gender was denoted as %OSI and used for quantitative assessment. The second %OSI measurement was performed 6 months after the first %OSI one. During the study period, individual treatment remained unchanged.

RESULTS

There were no significant differences in the 1st and 2nd %OSI between the ICS users and control subjects. However, the 2nd %OSI significantly decreased compared with 1st %OSI in female ICS users, although there were no significant changes in the male and female control subjects and male ICS users.

CONCLUSIONS

The 6 month management of asthma in the actual clinical setting, including regular ICS use, might have a harmful influence on the bone status of female asthmatic patients. It may be necessary to manage and treat female patients for potent corticosteroid-induced osteoporosis, although further analyses of bone status in asthma patient ICS users will be required.

Clinical question: What is the best approach to managing glucocorticoid-induced osteoporosis?

Glucocorticoid-induced osteoporosis is common, and the resulting fractures cause significant morbidity and mortality. Rapid bone loss and increased fracture risk occur soon after the initiation of glucocorticoid therapy and are dose dependent. The increase in fracture risk is partly independent of bone mineral density, probably as a result of changes in bone material properties and increased risk of falling. Fracture risk can be assessed using the FRAX algorithm, although risk may be underestimated in patients taking higher doses of glucocorticoids. Because of the rapidity of bone loss and increase in fracture risk after the start of glucocorticoid therapy, primary prevention should be advised in high-risk individuals, for example older women and men, individuals with a previous fracture history and those with low bone mineral density. Bisphosphonates are the front-line choice for the prevention of fracture in the majority of glucocorticoid-treated patients, with teriparatide as a second-line option. Calcium and vitamin D supplements should be co-prescribed unless there is evidence of an adequate dietary calcium intake and vitamin D status.

Role of teriparatide in treatment of glucocorticoid-induced osteoporosis

Glucocorticoids are commonly used in various fields within medicine. One of their most common and clinically significant side effects is glucocorticoid-induced osteoporosis (GIOP). GIOP is a disease leading to progressive decreases in bone mineral density, decreased bone strength, and increased risk of skeletal fractures. GIOP has a significant impact on the morbidity and health-related quality of life of the patients it affects. Glucocorticoids have deleterious effects on bone through promoting osteoblast apoptosis and inhibiting osteoblastogenesis. Teriparatide exerts anabolic effects on bone, so it is understandable why teriparatide is thought to be a rational treatment option. Clinical studies have indicated teriparatide is efficacious in the treatment of GIOP to improve bone mineral density values at the lumbar spine and femoral neck. Some evidence also suggests teriparatide may reduce rates of vertebral fractures in GIOP patients. Overall, this review of the current clinical evidence suggests teriparatide may be an efficacious and promising agent in the treatment of GIOP.

The effects of corticosteroids on bone growth and bone density

OBJECTIVE

To define the effects of both parenteral and inhaled corticosteroids on bone growth in children and the development of osteopenia and osteoporosis in children and adults.

DATA RESOURCES

Articles in PubMed and MEDLINE published from 1983 to 2008 were searched. Keywords used included corticosteroids and bone growth, osteopenia, osteoporosis, and bisphosphonates.

STUDY SELECTION

Publications reviewed include randomized, placebo-controlled studies of both children and adults.

RESULTS

Because systemic and high-dose inhaled corticosteroids affect bone growth of children taking these medications, stadiometry should be used to measure the growth of children. Osteoporosis due to repetitive courses of oral or parenteral corticosteroids and inhaled corticosteroids can develop gradually in the aging adult. Prophylaxis against osteoporosis requires an index of suspicion, assessment of bone density, supplemental calcium and vitamin D, and use of bisphosphonates to prevent bone fractures that could compromise the patient's quality of life.

CONCLUSION

Preventing corticosteroid-induced effects on bone metabolism can allow effective treatment of allergic disease without long-term adverse effects.

Emerging consensus on prevention and treatment of glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis is a common but still relatively neglected problem, with a low level of awareness among primary and secondary care physicians. Fractures appear early after initiation of treatment, and effective prophylaxis requires primary prevention in those at high risk of fracture. Bisphosphonates are the treatment of choice, and calcium and vitamin D supplements are also indicated in the majority of individuals. Organized care programs together with the use of evidence-based guidelines have the potential to improve significantly the management of this serious complication of glucocorticoid therapy.

The systemic safety of inhaled corticosteroid therapy: a focus on ciclesonide

OBJECTIVE

To review the potential systemic activity of ciclesonide and its active metabolite, desisobutyryl-ciclesonide, by evaluation of the effects on hypothalamic-pituitary-adrenal (HPA) axis function.

DATA SOURCES

EMBASE and MEDLINE searches using the keyword ciclesonide, without date restrictions, were conducted to identify published articles that related to clinical trials that included ciclesonide.

STUDY SELECTION

The primary articles that reported systemic safety data for ciclesonide were reviewed.

RESULTS

Ciclesonide (320-1,280 microg/d) demonstrated no detectable, clinically relevant effect on HPA axis function as evaluated by basal cortisol excretion measurements and dynamic stimulation tests. Furthermore, ciclesonide had no effect on the normal diurnal rhythm of endogenous cortisol secretion while simultaneously improving pulmonary function and reducing bronchial hyperresponsiveness. These results suggest that ciclesonide has a low systemic activity that may be attributable to unique pharmacologic properties, including a high degree of serum protein binding, a low oral bioavailability, and rapid systemic elimination, that reduce the level of systemically available pharmacologically active drug.

CONCLUSIONS

Even at the higher doses used to treat more severe cases of asthma, ciclesonide was observed to have no effect on HPA axis function. These data, in conjunction with the observed clinical efficacy, suggest that ciclesonide may have an improved therapeutic margin compared with some other currently available inhaled corticosteroid treatments and, therefore, the potential to improve therapeutic outcomes.

Self-reported diseases and the risk of non-vertebral fractures: the Tromsø study

We wanted to estimate the independent fracture risk associated with chronic diseases for men and women separately, adjusting for other known risk factors. This is a population-based study of all those who attended the fourth survey (1994-1995) in the Tromsø Study (n=27,159) who were followed until 31 December 2000 with respect to non-vertebral fractures. At baseline the age range was 25-98 years. Chronic disease cases were defined by self-report in questionnaires. All non-vertebral fractures were registered by computerized search in radiographic archives in the sole provider of radiographic service in the area. A total of 446 and 803 non-vertebral fractures were registered among men and women, respectively. Self-reported diabetes mellitus, stroke, asthma, hypo- and hyperthyroidism and psychiatric disorders were associated with increased fracture risk. Multivariate analyses showed an independent risk of fractures associated with self-reported diabetes mellitus, hypothyroidism and psychiatric disorders among men. Among women the independent risk was associated with self-reported asthma, hypo- and hyperthyroidism and psychiatric disorders. Self-reported heart disease had a protective effect on wrist fracture, especially in women. Increased burden of chronic diseases increase the risk of all non-vertebral (P<0.0001), wrist (P=0.005), proximal humerus (P=0.0004) and hip fracture (P=0.0002) in men, and for the proximal humerus (P=0.003) and hip fracture (P=0.04) in women. There was an independent fracture risk associated with self-reported diabetes mellitus, asthma, hypo- and hyperthyroidism and psychiatric disorders in men and women. Increasing burden of disease increased fracture risk in both men and women.

The effects of long term use of inhaled corticosteroids on linear growth, adrenal function and bone mineral density in children

In this study we aimed to investigate the long term effects of inhaled steroids on linear growth, adrenal function and bone mineral density. Thirty children with moderate asthma were randomly divided into two groups. Fifteen children (8 boys, 7 girls mean age; 10.6 +/- 2.1) were treated with budesonide (group 1), and 15 (9 boys, 6 girls, mean age; 9.6 +/- 2.4). with fluticasone propionate (group 2). Control group included 30 children. Anthropometric assessment, symptom and medication scores, pulmonary functions, bone mineral density, serum and urine cortisol levels and ACTH stimulation test were evaluated at the beginning of the study and after one year period. Symptom and medication scores, pulmonary functions improved significantly in both groups (p < 0.05). The mean annual growth was similar in group 1 and 2 and control group. Bone mineral density was comparable with control group at the beginning of the study and after one year. Mean serum cortisol level diminished at the end of the therapy but no significant differences were found between the initial and end values in respect to urine cortisol levels and cortisol/creatinine ratio. Of three groups ACTH stimulation test revealed that there were no significant difference between study and control groups. In conclusion, although we did not observed any side effects of inhaled corticosteroids we suggest that children treated with inhaled corticosteroids for a long time should be followed closely with respect to side effects.

Inhaled corticosteroids, bone mineral density and fracture in older people

The efficacy of inhaled corticosteroids in the treatment of asthma has been firmly established in a variety of settings. The majority of asthma management plans now recommend the use of inhaled corticosteroids at an early stage. This means that most patients with asthma will be prescribed an inhaled corticosteroid at some point in time and many patients with asthma will use these drugs for several years. Inhaled corticosteroids are also used in the treatment of other conditions, particularly chronic obstructive pulmonary disease (COPD). Since inhaled corticosteroids are absorbed into the systemic circulation, they can have systemic adverse effects, such as suppression of the hypothalamic-pituitary-adrenal axis and increasing the risk of bruising. However, perhaps the greatest concern for patients is whether the regular use of inhaled corticosteroids has an adverse impact on the bone mineral density and increases the risk of fracture. There is now accumulating evidence from epidemiological studies that the use of inhaled corticosteroids is inversely related to bone mineral density in a dose-dependent fashion. However, data from two clinical trials of moderately high doses of inhaled corticosteroids in patients with COPD have produced conflicting results and while the larger study of triamcinolone found a significant impact of this drug on bone mineral density, a smaller study of budesonide found no effect. Epidemiological research into the relationship between inhaled corticosteroids and fracture is at an early stage. To date, only three studies in this area have been reported, all of which have used different approaches to try to minimise the impact of bias and confounding. There is a lack of consistency between the final estimates of the impact of inhaled corticosteroids on fracture risk. However, taken together these data suggest that the short to medium term use of inhaled corticosteroids is associated with a small adverse effect on bone. Doctors and patients need to be aware of this risk and balance it against the known beneficial effects of inhaled corticosteroids.

Long-term fracture risk among children with asthma: a population-based study

Fracture risk among patients diagnosed with asthma in childhood is greater in males and oral corticosteroid users, but most fractures are of the appendicular skeleton and may relate to impaired skeletal development.

INTRODUCTION

There are no population-based data on fracture outcomes among the growing number of patients with asthma diagnosed in childhood.

MATERIALS AND METHODS

We conducted a population-based retrospective (historical) cohort study among 279 Rochester, Minnesota, residents who were <35 years of age (mean, 6.2 years) when first diagnosed with asthma. Fractures were ascertained by review of comprehensive community medical records, and cases were compared directly with age- and sex-matched controls in a stratified proportional hazards model. Risk factors for fractures among the asthma cases were assessed using Andersen-Gill time-to-fracture regression models.

RESULTS

During 6649 person-years of follow-up (median, 24.3 years/subject), 107 asthma patients experienced 189 fractures, for a crude fracture incidence rate of 2.8 per 100 person-years. The actuarially estimated cumulative fracture incidence after 20 years was 40% compared with 34% among controls (p = 0.122). There was no significant increase in overall fracture risk among cases compared to their age- and sex-matched controls (hazard ratio [HR], 1.3; 95% CI, 0.9-1.9), but males with asthma had a 2.6-fold greater risk of hand and finger fractures than control males. The independent predictors of overall fracture risk among the asthma patients included male gender (HR, 2.2; 95% CI, 1.5-3.2) and use of oral corticosteroids (HR, 2.0; 95% CI, 1.2-3.1) or anti-cholinergic agents (HR, 3.9; 95% CI, 1.5-10).

CONCLUSIONS

Rather than osteoporotic fractures of the axial skeleton, oral corticosteroid therapy was associated here with limb fractures, suggesting a relationship with impaired development of a biomechanically competent skeleton. Additional studies are needed to assess this possibility.

Asthma and therapeutics: inhaled corticosteroids, corticosteroid osteoporosis, and the risk of fracture in chronic asthma

Current guidelines for the diagnosis and treatment of osteoporosis do not address the risks to bone density and the likelihood of fracture that may be associated with inhaled corticosteroid treatment for asthma. This review outlines an approach to the use of bone densitometry in clinical practice for the diagnosis, prevention, and treatment of osteoporosis in asthmatic patients receiving inhaled corticosteroid therapy.

Effects of alendronate on bone mineral density and bone metabolic markers in postmenopausal asthmatic women treated with inhaled corticosteroids

We have recently shown that long-term use of inhaled corticosteroids decreases bone mineral density (BMD) of the lumbar spine in postmenopausal asthmatic women. The present study aimed to evaluate the efficacy of alendronate in comparison with that of alfacalcidol (1-alpha-hydroxyvitamin D(3)) for the treatment of BMD reduction in postmenopausal asthmatic patients who had inhaled corticosteroid therapy without regular use of systemic corticosteroids. Twenty-eight postmenopausal asthmatic patients with BMD T score of -1.0 or less were randomized to receive alendronate (5 mg/d) or alfacalcidol (1 microg/d). Bone mineral density was determined at baseline and 12 months after the treatment, and biochemical markers of bone metabolism were measured at baseline and after 6 and 12 months of treatment. The mean (+/-SD) BMD values at the lumbar spine, the total hip, and the Ward's triangle significantly increased by 4.9 +/- 4.5% (P = .0005), 2.4 +/- 2.2% (P = .0005), and 3.6 +/- 5.2% (P = .02) at 12 months in the alendronate group, whereas the corresponding values did not significantly change in the alfacalcidol group. In the alendronate group, urinary N-telopeptide (NTx), serum osteocalcin, and serum alkaline phosphatase concentrations significantly decreased, and serum intact parathyroid (PTH) level significantly increased, from baseline at both 6 and 12 months. In the alfacalcidol group, urinary NTx showed modest but significant decrease, although the extent of the change was smaller than that in the alendronate group. We concluded that alendronate was effective to improve reduced BMD in postmenopausal asthmatic patients on inhaled corticosteroid therapy through the mechanism of inhibiting bone resorption.

Bone mineral status in children with cow milk allergy

To investigate bone mineral status in children with verified cow milk allergy for more than 4 yr compared with a large reference population of 343 local healthy controls. Whole body bone mineral content (BMC), projected bone area and bone mineral density (BMD) were determined by dual energy x-ray absorptiometry in nine children (8-17 yr old, one girl and eight boys). All children had cow milk allergy for more than 4 yr. All children had asthma and was treated with corticosteroids. BMC and BMD were reduced for age (p < 0.01). Height for age was significantly reduced (p < 0.01), indicating 'short' bones. BMC for bone area was borderline reduced (p = 0.05), indicating reduced bone mineralization. The growth of the children was reduced compared with there parents and siblings (p < 0.01), and the bone age was retarded (mean 1.4 yr, p < 0.01). Calcium consumption calculated from food intake was about 25% of the recommended. All laboratory tests were normal. Short bones were the main reason for reduced BMC and BMD for age in children with cow milk allergy, but a borderline low BMC for bone area indicated reduced bone mineralization of the bones. A supplementation of calcium to children with cow milk allergy is recommended.

Glucocorticoid-induced osteoporosis

Therapeutic use of glucocorticoids can lead to many well-known adverse events. Of all potential serious side effects, glucocorticoid-induced osteoporosis (GIOP) is one of the most devastating complications of protracted glucocorticoid therapy in rheumatoid arthritis. GIOP is the most common form of drug-induced osteoporosis. Although much has been written about the association of glucocorticoids with bone disease among patients with chronic inflammatory conditions, many issues remain unsettled. This article focuses on areas of continued controversies, including the epidemiology and pathogenesis of GIOP, specification of a "safe" dose, methods for diagnosis of GIOP, and an evidence-based approach for GIOP prevention.

Effect of inhaled steroids on bone mineral density: a meta-analysis

Inhaled corticosteroids are currently considered first-line agents for the treatment of asthma. Medium- to long-term administration of inhaled steroids may be associated with bone loss. Various studies have evaluated their effect on bone mineral density (BMD); some have shown loss of BMD with steroid treatment, but others have failed to do so. The present meta-analysis was undertaken to determine the possible effect of inhaled steroids on bone density. Literature was collected using computerized (MEDLINE) and manual searches using index medicus and checking cross-references of the published articles. The studies identified were screened for inclusion/exclusion criteria. Grouped means (XT/XC) and pooled standard deviations (SDT/SDC) for the treatment group (XT[95% CI] = 1.144 [1.019-1.269]; SDT = 0.163, g/cm2) and control group (XC [95% CI] = 1.193 [1.073-1.313]; SDC = 0.157, g/cm2) were worked out respectively for the selected studies. Finally, a comparison between grouped means of steroid-treated and control groups was done by two-sample t-test at the 5% level of significance. The results of the meta-analysis showed that although the mean BMD of the steroid-treated group was reduced by 4.1% as compared to the control group, this failed to achieve statistical significance (p = 0.8; 95% CI for the mean difference between two groups = 0.028-0.070 g/cm2). It is concluded that inhaled steroids for the treatment of asthma can be considered safe with respect to their effect on bone loss.

Is there an association between inhaled corticosteroids and bone density in postmenopausal women?

BACKGROUND

During the last decades, there has been increased concern about the association between oral corticosteroid (OC) therapy and osteoporosis.

OBJECTIVE

The question currently discussed is whether inhaled corticosteroids (ICs) in recommended doses have any clinically relevant effects on bone mineral density (BMD).

METHODS

We compared BMD in postmenopausal women exposed to corticosteroids only in inhaled form (IC group, n = 106) with that in women not exposed to corticosteroids (unexposed group, n = 674). BMD was also studied in 49 women exposed to OCs, intra-articular injections, or both in addition to ICs (OC group). The women were recruited from a population-based prospective cohort study.

METHODS

We used a dietary survey, bone density measurement of the forearm, and a health questionnaire including an interview about past and present medication use.

RESULTS

Mean BMD did not significantly differ between the IC group (0.434 g/cm2) and the unexposed group (0.429 g/cm2). The mean duration and dose of ICs was 8.2 +/- 5.03 years and 853 microg daily. Within the IC group, BMD stratified for cumulative dose of IC, duration, or current dose greater than or less than 1000 microg did not differ. BMD in the OC group was lower than that in the IC group (0.408 vs 0.434 g/cm2).

CONCLUSION

No difference in BMD was noted between the IC group and unexposed control subjects, nor was any dose-response relationship observed between IC therapy and BMD.

Repetition of an unusual stress fracture in an anorexic man: a case report

Stress fractures of the fibula commonly occur distally in runners, whereas stress fractures of the proximal fibula are uncommon and typically occur in jumpers. Furthermore, it is rare for a stress fracture to be repeated in the same bone. We report a case of a repeated stress fracture of the proximal fibula in a male runner with abnormal gait that primarily involved excessive pronation. Unusual risk factors in this case were anorexia nervosa and use of an inhaled corticosteroid. The patient was treated conservatively, and healing of the fracture was completed at 12 weeks.

Risk factors for osteoporosis in a subgroup of elderly men in a Veterans Administration nursing home

BACKGROUND

General risk factors for osteoporosis in men include cigarette smoking, alcohol consumption, and diseases known to affect calcium or bone turnover. The aim of this study was to determine the specific incidence and major risk factors for osteoporosis in those at high risk for falling in a Veterans Administration nursing home that included a high proportion of psychiatric patients.

METHODS

We performed a cross-sectional analysis of Veterans Administration Medical Center nursing home residents with high fall risk. Thirty-nine men with a previous episode of falling or who were considered to be at high fall risk were enrolled. A review of the medical histories and pertinent hormonal and biochemical laboratory values was performed. Bone mineral density was measured by performing dual energy x-ray absorptiometry for all participants.

RESULTS

We reviewed the medical records of 39 male nursing home residents with high fall risk. The patients' mean age was 74.7 +/- 6.8 years. A significant (p = 0.00045) association was found between chronic obstructive pulmonary disease and osteoporosis independent of oral corticosteroid use. Additional risk factors found to be associated with osteoporosis included hypogonadism, lower body weight, antipsychotic medication use, and smoking.

CONCLUSION

In a Veterans Administration nursing home population at high risk for falls, including psychiatric patients, chronic obstructive pulmonary disease independent of the use of corticosteroids, lower body weight, hypogonadism, use of antipsychotic medications, and smoking was found to be associated with osteoporosis.

COPD and osteoporosis

Osteoporosis, with resulting fractures, is a significant problem in patients with advanced COPD. The etiology for the bone loss is diverse but includes smoking, vitamin D deficiency, low body mass index, hypogonadism, sedentary lifestyle, and use of glucocorticoids. Effective strategies to prevent bone loss and/or to treat osteoporosis include calcium and vitamin D, hormone replacement when indicated, calcitonin, and bisphosphonate administration. However, many patients remain undiagnosed until their first fracture because of the lack of recognition of the disease. With an increased awareness by pulmonologists and the increased use of preventive strategies, the impact of osteoporosis on those patients with COPD should decrease.

Inhaled corticosteroid effects on bone metabolism in asthma and mild chronic obstructive pulmonary disease

BACKGROUND

Inhaled corticosteroids form the main therapy for asthma, but there is increasing concern about the potential systematic effects of long-term inhaled corticosteroids including their effect on bone metabolism and bone loss.

OBJECTIVES

To determine the effect of inhaled corticosteroids use on biochemical markers of bone turnover, bone mineral density and the development of fractures.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register, electronic reference databases, UK National Research Register, bibliographies of included studies, and contacted pharmaceutical companies.

SELECTION CRITERIA

Randomised trials of the effect of inhaled steroid versus placebo on markers of bone function and metabolism, in adults with asthma or mild COPD.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extracted from the papers included (2 reviewers per paper) and from additional data supplied by the authors.

MAIN RESULTS

Of 438 references found, seven met the inclusion criteria. Three studies were in healthy subjects asthma or COPD. The patients were generally less than 60 years old and the male:female ratio was 2:1. There was no evidence of increased risk of loss of bone mineral density (BMD) or fractures. There was no significant change in osteocalcin at conventional doses of inhaled corticosteroids (Standardised Mean Difference [SMD] -0.34 (95% Confidence Interval [CI] -0.72, 0.04), although a statistically significant change was seen in those studies using experimental doses of inhaled steroid in excess of the doses recommended by the British Thoracic Society SMD 0.97 (95% CI -1.61, -0.34). A statistically significant change in parathyroid hormone seen in one small short trial (n=10, 6 weeks) may have been due to the trial design and outcome measurements used.

REVIEWER'S CONCLUSIONS

In patients with asthma or mild COPD, there is no evidence of an effect of inhaled corticosteroid at conventional doses given for two or three years on BMD or vertebral fracture. Higher doses were associated with biochemical markers of increased bone turnover, but data on BMD and fractures at these doses are not available. There is a need for further, even longer term prospective studies of conventional and high doses of inhaled corticosteroids.

Effects of asthma and asthma therapies on bone mineral density

With improvements in techniques for measuring bone mass, interest and concern have increased about the effects of asthma therapies, particularly corticosteroids, on bone mineral density. Whether asthma itself causes bone loss remains unclear. Studies evaluating the effect of asthma therapies on bone mineral density are often difficult to interpret because of methodologic problems. These studies show that oral corticosteroids are associated with a reduction in bone mineral density and an increased risk of fracture. Studies evaluating the effects of inhaled corticosteroids on bone mineral density provide conflicting data, but there is increasing evidence that inhaled corticosteroids may have an adverse effect on bone. However, the benefits of inhaled corticosteroids in the treatment of asthma remain far greater than the risks. The data for the effects of other asthma therapies on bone mineral density are limited.

Effects of inhaled corticosteroid and short courses of oral corticosteroids on bone mineral density in asthmatic patients : a 4-year longitudinal study

BACKGROUND

It is not certain whether inhaled corticosteroid (ICS) therapy reduces bone mineral density (BMD) in asthmatic patients. In addition, the potential risk of osteoporosis associated with the rescue use of short courses of oral corticosteroids (SC-OCS) is unclear.

OBJECTIVE

To evaluate the effect of inhaled beclomethasone dipropionate (BDP) and SC-OCS on BMD in asthmatic patients.

DESIGN

A 4-year longitudinal study.

METHOD

Lumbar BMD was measured twice by dual-energy x-ray absorptiometry at a mean (+/- SD) interval of 4.2 +/- 0.1 years in 35 asthmatic adults (15 men and 20 postmenopausal women; mean age at the second evaluation, 60.6 +/- 11.5 years) who had been treated with BDP and SC-OCS.

RESULTS

The average period of BDP treatment was 7.7 +/- 2.2 years (range, 4.8 to 13.0 years) at the second evaluation. During the study period, the daily dose of BDP was 765 +/- 389 microg (range, 100 to 1,730 microg), and the frequency of SC-OCS was 1.9 +/- 2.7 courses per year (range, 0.0 to 8.9 courses per year). As a whole, lumbar BMD was unchanged during the course of the study, whereas the Z score (ie, the percentage of normal value predicted from age and sex) increased significantly. Changes in BMD and Z scores in patients receiving high doses of BDP (ie, > 1,000 microg/d; n = 9) were not significantly different from those of patients receiving lower doses (ie, <or= 1,000 microg/d; n = 26). However, patients receiving frequent SC-OCS (ie, > 2.5 courses per year; n = 9) showed a significantly greater loss in BMD and Z score compared with those receiving sporadic courses (ie, <or= 2.5 courses per year; n = 26) (p = 0.002 and p = 0.035, respectively).

CONCLUSIONS

ICS therapy per se does not affect BMD, whereas frequent SC-OCS may do so.

Effects of inhaled glucocorticoids on bone density in premenopausal women

BACKGROUND

Inhaled glucocorticoids are the most commonly used medications for the long-term treatment of patients with asthma. Whether long-term therapy with inhaled glucocorticoids reduces bone mass, as oral glucocorticoid therapy does, is controversial. In a three-year prospective study, we examined the relation between the dose of inhaled glucocorticoids and the rate of bone loss in premenopausal women with asthma.

METHODS

We studied 109 premenopausal women, 18 to 45 years of age, who had asthma and no known conditions that cause bone loss and who were treated with inhaled triamcinolone acetonide (100 microg per puff). We measured bone density by dual-photon absorptiometry at base line, at six months, and at one, two, and three years. Serum osteocalcin and parathyroid hormone and urinary N-telopeptide, cortisol, and calcium excretion were measured serially. We measured inhaled glucocorticoid use by means of monthly diaries, supported by the use of an automated actuator-monitoring device.

RESULTS

Inhaled glucocorticoid therapy was associated with a dose-related decline in bone density at both the total hip and the trochanter of 0.00044 g per square centimeter per puff per year of treatment (P= 0.01 and P=0.005, respectively). No dose-related effect was noted at the femoral neck or the spine. Even after the exclusion of all women who received oral or parenteral glucocorticoids at any time during the study, there was still an association between the decline in bone density and the number of puffs per year of use. Serum and urinary markers of bone turnover or adrenal function did not predict the degree of bone loss.

CONCLUSIONS

Inhaled glucocorticoids lead to a dose-related loss of bone at the hip in premenopausal women.

Features of asthma in the elderly

Asthma has been considered a rare disease in the elderly, but recent studies have shown that it is as common in the elderly as in the middle-aged population. Diagnosis of asthma is often overlooked in older patients, leading to undertreatment. Spirometry, determination of expiratory flow lability, and histamine challenge tests are tools that are as usefulfor the evaluation of elderly asthmatics as they areforyoungerpatients. Asthma is more severe in the elderly, especially in long-standing asthmatics. Treatment of asthma in the elderly should follow the same stepwise guidelines that are recommended for all age groups, though it will require more intense monitoring. An aggressive treatment approach to mild and moderate asthma in young people is the best hope of changing the future trends of asthma in the elderly.

Effect of the long-term use of inhaled corticosteroids on bone mineral density in asthmatic women

OBJECTIVE

Inhaled corticosteroids have become a key element in the maintenance treatment of bronchial asthma. Recent studies have shown that administration of inhaled corticosteroids is associated with evidence of derangement in bone turnover. Therefore, we studied the bone mineral density (BMD) of asthmatic women receiving long-term inhaled corticosteroids and compared them with healthy individuals matched for age, sex, menopausal status and body mass index.

METHODOLOGY

Thirty-two female patients with bronchial asthma, who had been using inhaled corticosteroids (beclomethasone dipropionate 750-1500 microg/day) regularly for at least 3 months, were included in the study. Bone mineral density measurements were done with dual X-ray absorptiometry in the lumbar area of the spine and the hip. Detailed laboratory examination was also done for the patients and 26 controls.

RESULTS

There was a significant decrease in BMD of the patient group at the lumbar region and femur as compared with normal controls. In the patients there was a significant negative correlation between the duration of therapy, daily and cumulative doses, and BMD at the lumbar region but not BMD at the femur.

CONCLUSIONS

These results indicate that long-term use of inhaled corticosteroids is associated with significant bone loss in asthmatic women and is especially related to the duration of therapy. Therefore, it is necessary to appropriately screen and give prophylactic treatment to those who are likely to develop osteoporosis from inhaled corticosteroid treatment.

Inhaled corticosteroids reduce bone mineral density in early postmenopausal but not premenopausal asthmatic women

Inhaled corticosteroids are widely used in the treatment of bronchial asthma, but it is still uncertain whether long-term use of the inhaled corticosteroids affects bone metabolism in asthmatic patients. In this study, we examined the effect of inhaled beclomethasone dipropionate (BDP) on bone mineral density (BMD) and biochemical markers of bone metabolism in pre- and early postmenopausal asthmatic women. Thirty-six (17 premenopausal and 19 early postmenopausal) asthmatic women and 45 healthy control (24 premenopausal and 21 early postmenopausal) women were investigated. All the asthmatic patients were treated with BDP (542 +/- 298 microg/day; 100-1200 microg/day) without any systemic administration of corticosteroids for at least 1 year. In premenopausal women, BMD as well as the biochemical markers of bone metabolism did not differ between control subjects and BDP-treated asthmatic patients. By contrast, in early postmenopausal women, BMD was significantly lower in BDP-treated asthmatic patients than in control subjects. In these early postmenopausal women, serum intact osteocalcin concentration was lower in the BDP-treated asthmatic patients than in the control subjects whereas urinary free pyridinoline (F-PYD) and free deoxypyridinoline (F-DPD) concentrations did not differ between the groups. Thus, early postmenopausal, but not premenopausal, asthmatic patients who were treated with inhaled BDP had reduced BMD, which was associated with a decreased level of the bone formation marker. Ovarian hormones may be protective against the adverse effect of inhaled BDP on bone metabolism in the premenopausal patients.

Use of inhaled corticosteroids and risk of fractures

Treatment with systemic corticosteroids is known to increase the risk of fractures but little is known of the fracture risks associated with inhaled corticosteroids. A retrospective cohort study was conducted using a large UK primary care database (the General Practice Research Database [GPRD]). Inhaled corticosteroid users aged 18 years or older were compared with matched control patients and to a group of noncorticosteroid bronchodilator users. Patients with concomitant use of systemic corticosteroids were excluded. The study comprised 170,818 inhaled corticosteroid users, 108,786 bronchodilator users, and 170,818 control patients. The average age was 45.1 years in the inhaled corticosteroid, 49.3 years in the bronchodilator, and 45.2 years in the control groups. In the inhaled corticosteroid cohort, 54.5% were female. The relative rates (RRs) of nonvertebral, hip, and vertebral fractures during inhaled corticosteroid treatment compared with control were 1.15 (95% CI, 1.10-1.20), 1.22 (95% CI, 1.04-1.43), and 1.51 (95% CI, 1.22-1.85), respectively. No differences were found between the inhaled corticosteroid and bronchodilator groups (nonvertebral fracture RR = 1.00; 95% CI, 0.94-1.06). The rates of nonvertebral fractures among users of budesonide (RR = 0.95; 95% CI, 0.85-1.07) and fluticasone propionate (RR = 1.03; 95% CI, 0.71-1.49) were similar to the rate determined for users of beclomethasone dipropionate. We conclude that users of inhaled corticosteroids have an increased risk of fracture, particularly at the hip and spine. However, this excess risk may be related more to the underlying respiratory disease than to inhaled corticosteroid.

Bone mineral density in women with asthma on long-term inhaled corticosteroid therapy

BACKGROUND

Inhaled corticosteroids (ICS) have become first line agents in the management of moderate-to-severe asthma. Long-term use of ICS is associated with decreased bone mineral density (BMD).

OBJECTIVE

To investigate the prevalence of BMD loss and its severity in women with asthma on long-term ICS.

METHODS

Fifty-six women with asthma on long-term ICS, attending an inner-city allergy clinic were selected to undergo bone densitometry in order to evaluate the association between BMD and the long-term use of ICS at different dose ranges.

RESULTS

Women (60.7%) had decreased BMD either at the lumbar spine or hip region. Among postmenopausal women, 17.1% of those <65 years and 42.9% of those > or =65 years had osteoporosis compared with 5.7% (95% CI-3.9% to 8.5%) of those <65 and 29.3% (95% CI-25.7%-33.5%) of those > or =65 years reported in the NHANES III survey. The prevalence of low BMD increased as ICS dose increased from 5% in the low dose group to 50% in the high dose group (P < .002). There were significant linear trends of decline by dose in mean BMD for the hip (P < .001) and the lumbar spine (P < .002). Women who received medium or high doses of ICS had significantly greater bone loss than those receiving low doses.

CONCLUSION

The findings of increasing BMD loss with increasing ICS dose reinforce the necessity to monitor BMD periodically in women on ICS, particularly in the high risk postmenopausal group and those on medium to high doses. There should be a concurrent continual attempt to lower the dose by supplemental nonsteroidal controller medications and providing nutritional and pharmacologic treatment of identified BMD loss in these patients.

Effect of an inhaled glucocorticoid, flunisolide, on bone mineral density: a 2-year prospective, controlled trial

OBJECTIVE

To determine the long-term effect of an inhaled glucocorticoid, flunisolide, on bone mineral density in a prospective, controlled study.

METHODS

Patients with asthma treated with inhaled glucocorticoids, but not requiring other types of glucocorticoid treatment, were recruited as study patients (N = 11). All study patients were treated with inhaled flunisolide, 500 mg twice a day for a 2-year period, for consistency. Patients with asthma not requiring any type of glucocorticoid treatment were recruited as control subjects (N = 18). All patients were between the ages of 30 and 50 years, and all female patients were premenopausal. Measurements of bone mineral density, serum bone-specific alkaline phosphatase, serum osteocalcin, 24-hour urine hydroxyproline-to-creatinine ratio, forced expiratory volume in 1 second/forced vital capacity, and forced expiratory flow, midexpiratory phase were obtained at baseline and repeated in 1 year and again in 2 years.

RESULTS

No statistically significant changes were noted in bone mineral density measured at the lumbar spine, femoral neck, Ward's triangle, or femoral trochanter in the users of inhaled flunisolide in comparison with the control subjects at 1 year or at 2 years, with one exception. The percentage change from baseline of bone mineral density measured at the femoral trochanter at 1 year was greater in the inhaled flunisolide users than in the control group, 3.1% versus -0.8%, respectively (P = 0.01). No statistically significant changes were found in markers of bone turnover or measures of asthma severity.

CONCLUSION

Inhaled flunisolide, administered in standard doses, had no deleterious effect on bone mineral density or on biochemical markers of bone turnover after a 2-year period.

Effect of one year treatment with inhaled fluticasone propionate or beclomethasone dipropionate on bone density and bone metabolism: a randomised parallel group study in adult asthmatic subjects

BACKGROUND

There is some concern that prolonged treatment with high doses of inhaled corticosteroids may have a detrimental effect on bone mass. The aim of this one year study was to investigate the effects of low and high doses of fluticasone propionate (FP) (400 microg/day and 750 microg/day) and beclomethasone dipropionate (BDP) (800 microg/day and 1500 microg/day) on bone mass and metabolism.

METHODS

This was a multicentre, double blind, parallel group study involving 69 mild to moderate asthmatic subjects who were randomised to treatment as follows: 22 to FP400, 21 to BDP800, 13 to FP750, and 13 to BDP1500. Their mean age was 39 years, 67% were men, and all the women were premenopausal.

RESULTS

The results of peripheral quantitative computed tomographic (pQCT) measurements (primary variable) showed that, compared with baseline values, there was no loss of trabecular or integral (cortical and trabecular) bone in the distal radius or tibia in any of the patients over the 12 month study period. No consistent pattern emerged from the analysis of changes from baseline in markers of bone formation and resorption after six and 12 months of treatment.

CONCLUSION

The results of this study provide reassuring prospective one year data showing that inhaled corticosteroids, in the range of doses used, had no adverse effects on bone mass and metabolism in this group of asthmatic patients.

Inhaled corticosteroid use and bone-mineral density in patients with asthma

BACKGROUND

Inhaled corticosteroids are absorbed into the systemic circulation, but the extent to which they have adverse effects on bone is uncertain. The question is important since 3% of the European population take an inhaled corticosteroid regularly and may do so for many years.

METHODS

We studied the dose-response relation between cumulative inhaled corticosteroid dose and bone-mineral density at the lumbar spine and proximal femur in 196 adults (119 women) with asthma aged 20-40 years. Patients had taken an inhaled corticosteroid regularly for at least 6 months, and had had limited exposure to systemic steroids. Cumulative dose of inhaled corticosteroid was calculated from questionnaires and computerised and written general-practice records, and its effect on bone-mineral density was estimated by multiple regression analysis.

FINDINGS

Median duration of inhaled corticosteroid treatment was 6 years (range 0.5-24), and median cumulative dose was 876 mg (87-4380). There was a negative association between cumulative dose of inhaled corticosteroid and bone-mineral density at the lumbar spine (L2-L4), femoral neck, Ward's triangle, and trochanter, both before and after adjustment for the effects of age and sex. A doubling in dose of inhaled corticosteroid was associated with a decrease in bone-mineral density at the lumbar spine of 0.16 SD (95% CI 0.04-0.28). Similar decreases were found at the femoral neck, Ward's triangle, and trochanter. Adjustment for potential confounding factors including physical activity and past oral, nasal, dermal, and parenteral corticosteroids did not weaken the associations.

INTERPRETATION

This study provides evidence of a negative relation between total cumulative dose of inhaled corticosteroid and bone-mineral density in patients with asthma.

Long-term corticosteroid therapy induces mild changes in trabecular bone texture

The relative roles of bone mineral density (BMD) decrease and of microarchitectural changes in corticosteroid-induced osteoporosis (CIOP) are debated. Our objective has been to evaluate both bone microarchitecture (by a fractal analysis of texture on radiographs) and BMD in corticosteroid (CS)-treated patients. In this study, 60 patients from a rheumatology unit with a mean age of 60.6+/-14.8 years taking CS therapy for more than 6 months and a cumulative dose of prednisone over 1 g and 57 controls among age-matched patients and hospital staff were recruited. Bone diseases and bone-modifying drugs (except calcium, vitamin D, and hormonal replacement therapy [HRT]) were considered as exclusion criteria. A fractal analysis of trabecular bone texture was performed on calcaneus radiographs after an oriented analysis in 18 directions. The fractal analysis was based on the fractional Brownian motion model. Results were expressed by H parameter (H = 2 - fractal dimension) in each direction, Hmean being the average of 18 directions, Hmini the minimum, and Hmaxi the maximum. BMD was measured by double-energy X-ray absorptiometry (DEXA) at the femoral neck (FN) and lumbar spine (LS). The odds ratios (OR) were calculated for a variation of 1 SD. The mean duration and dose of CS therapy was 5.6+/-6.6 years and 16.9+/-19.7 g. CS therapy was significantly correlated to a decrease in FN or LSBMD: OR = 1.95, 95% confidence interval (CI, 1.29-2.97) and OR = 3.19 (CI, 1.80-5.66), respectively. The Hmean and Hmaxi were significantly lower in the cases than in the controls: P = 0.03 and P = 0.02; OR = 1.67 (CI, 1.10-2.54) and OR = 1.75 (CI, 1.05-2.37). A similar trend was observed with Hmini but the difference did not reach the level of statistical significance: P = 0.06, OR = 1.57 (CI, 1.05-2.37). This study was repeated among cases and controls who had never taken HRT (respectively, n = 40 and n = 39). The results were similar. Among patients taking CS therapy, the presence of nontraumatic fractures was inversely related to BMD values but not to texture parameters. These data have shown that long-term CS therapy induces both BMD decrease and trabecular bone texture changes. The effect of CS therapy was much stronger on BMD than on the fractal H parameter. These results are in accordance with previous studies showing a lower effect of CS therapy on bone microarchitecture than on bone mass. These results can be contrasted with those observed in women with postmenopausal osteoporosis and vertebral crush fractures in which the variations in the fractal parameters are more significant than the BMD variations.

Beclomethasone for asthma in children: effects on linear growth

BACKGROUND

Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.

OBJECTIVES

To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.

SEARCH STRATEGY

The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.

SELECTION CRITERIA

Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.

DATA COLLECTION AND ANALYSIS

Data related to the clinical outcome "change in growth" were extracted by two reviewers working independently

MAIN RESULTS

One hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).

REVIEWER'S CONCLUSIONS

In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.

Declining bone mass in men with chronic pulmonary disease: contribution of glucocorticoid treatment, body mass index, and gonadal function

BACKGROUND

Men with chronic lung disease (CLD) are at risk for osteoporosis, but the relative contributions of their chronic pulmonary disease, glucocorticoid therapy, and other factors toward loss of bone has not been established. Understanding the relative importance of these factors would assist in selecting patients for bone densitometry screening and in policy decisions regarding Medicare reimbursement.

OBJECTIVE

To identify patients with CLD who are most likely to benefit from bone densitometry screening based on clinical and biochemical measures.

DESIGN

Cross-sectional medical survey.

PATIENTS

Patients with CLD who were treated with either oral, inhaled, or no glucocorticoid therapy. A control group without lung disease was recruited from the same clinic population.

MEASUREMENTS

Dual-energy X-ray absorptiometry was obtained for each group, and the association between bone mass and clinical variables, glucocorticoid use, gonadal hormones, and biochemical markers of bone metabolism was determined.

RESULTS

Osteoporosis (a T score < -2.5 at the hip or spine) was five times as likely in patients with CLD as in control subjects. Although the prevalence of osteoporosis was higher (ninefold) after chronic glucocorticoid therapy, patients with CLD who had never been treated with glucocorticoids had a substantial (fourfold) risk of osteoporosis. Chronic inhaled glucocorticoid therapy offered no protection from bone loss compared to treatment with oral glucocorticoids. Of the clinical and biochemical measures that were obtained, bone mass was weakly correlated with body mass index (BMI), serum estradiol-17beta, and N-telopeptide, but not with testosterone, alkaline phosphatase, bone-specific alkaline phosphatase, or osteocalcin.

CONCLUSION

Patients with CLD should be considered for bone densitometry screening regardless of glucocorticoid use. Those patients with a low BMI and/or decreased serum estradiol-17beta comprise a subgroup with increased risk for osteoporosis.

Chronic glucocorticoid therapy-induced osteoporosis in patients with obstructive lung disease

Long-term glucocorticoid (GC) therapy has been instrumental in decreasing morbidity and mortality in a variety of chronic inflammatory diseases, including persistent asthma. Long-term GC therapy is also widely prescribed for COPD. One of the important and often unrecognized side effects of chronic GC therapy is secondary osteoporosis. The risk of GC-induced bone loss is roughly correlated with daily dose, duration, and total cumulative lifetime dose of GC treatment. Oral prednisone increases the risk of bone loss and fracture. High doses of inhaled GCs may also increase the risk of osteopenia/osteoporosis, but the risk appears to be less than that associated with oral GCs. Hormone replacement therapy, oral and parenteral bisphosphonates, supplemental calcium and vitamin D, calcitonin, and fluoride compounds have been used, experimentally, in the management of GC-induced bone loss. Asthma and COPD specialists are key prescribers of oral and inhaled steroids and are likely to encounter patients with significant bone loss. Despite known risk factors and the availability of reliable diagnostic tools to recognize bone loss, the opportunity to slow, reverse, and treat bone loss is often missed. We present a review of the current literature regarding the incidence, treatment, and prevention of osteopenia/osteoporosis secondary to chronic GC therapy in adult asthma and COPD patients. Guidelines are presented regarding the identification of patients at risk for developing GC-induced secondary bone loss, and therapeutic alternatives are discussed.