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

Adrenal function in cystic fibrosis

Cystic fibrosis (CF) is not known to directly affect the adrenal gland, but commonly used CF therapies do impact the function of the hypothalamic-pituitary-adrenal (HPA) axis. By binding to the glucocorticoid receptor, medications such as inhaled and oral corticosteroids can enhance the systemic effects of cortisol and result in iatrogenic Cushing syndrome. Prolonged use suppresses the body's ability to make cortisol, resulting in iatrogenic adrenal insufficiency upon medication discontinuation. Chronic use of inhaled and oral corticosteroids can negatively affect bone health, growth, and glucose metabolism. This chapter provides practical guidelines regarding the screening, diagnosis, and treatment of iatrogenic adrenal insufficiency. As the guidelines are mainly derived from the asthma literature, this chapter also highlights the need for studies to evaluate the impact of CF therapies on adrenal function and other CF-endocrinopathies.

Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children

BACKGROUND

Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology.

METHODS

An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included.

RESULTS

Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted.

CONCLUSION

In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.

Trabecular Bone Score Is More Sensitive to Asthma Severity and Glucocorticoid Treatment Than Bone Mineral Density in Asthmatics

PURPOSE

In asthmatic patients, treatment with corticosteroids, in addition to conventional risk factors for osteoporosis, may lead to bone loss. Trabecular bone score (TBS) is an indirect new parameter of bone quality. This study aimed to evaluate TBS in asthmatics in comparison to propensity score-matched controls and to investigate correlations between TBS and cumulative systemic and inhaled corticosteroid doses 1 year prior to bone mineral density (BMD) measurement in patients with asthma.

METHODS

In total, 627 patients with asthma and the same number of non-asthmatic controls matched for sex and age were included in this retrospective cohort study. TBS was calculated in the lumbar region, based on 2 dimensional projections of dual-energy X-ray absorptiometry.

RESULTS

Patients with severe asthma exhibited lower vertebral TBS values (1.32 ± 0.1) than those with non-severe asthma (1.36 ± 0.1, P = 0.001), with non-active asthma (1.38 ± 0.1, P < 0.001), and without asthma (1.39 ± 0.1, P < 0.001). No significant differences in BMD were noted among the study groups. TBS was significantly correlated with cumulative systemic and inhaled corticosteroid doses as well as asthma duration, lung function and airway hyper-responsiveness. A generalized linear model revealed that age, severe asthma, and frequency of oral corticosteroid burst were significant predictors for TBS levels.

CONCLUSIONS

TBS can be used as an early indicator of altered bone quality stemming from glucocorticoid therapy or, possibly, more severe asthma.

Impact of treatment with inhaled corticosteroids on bone mineral density of patients with asthma: related with age

The effect of inhaled corticosteroid on bone mineral density (BMD) was investigated in 44 asthmatic patients after median treatment duration of 6.5 years. Compared with controls, BMD decreased only in patients aged <50 years in both the spine (11.3 %, p = 0.013) and hip (8.8 %, p = 0.044), whereas in patients ≥50 years BMD did not decrease significantly.

INTRODUCTION

The results of studies which addressed the impact of inhaled corticosteroid (ICS) therapy on BMD of patients with asthma are conflicting. This case-control study aimed to compare BMD status in ICS user with asthma with healthy controls according to age.

METHODS

BMD at the lumbar spine (LS), femoral neck (FN) was measured by dual energy X-ray absorptiometry (DEXA). Patients and controls were compared according to BMD gr/cm(2), BMD T-score, BMD Z-score, frequency of osteoporosis (defined as BMD T-score ≤-2.5), and frequency of patients with BMD Z-score <-1 at LS and FN with regard to age <50 and ≥50 years old.

RESULTS

Forty-four ICS user patients (females 63.6 %) with median treatment duration of 6.5 years and 50 controls (females, 69.4 %) with respective mean age of 49.2 ± 9.5 and 47.4 ± 10.5 years (p = 0.38 and p = 0.35) entered the study. Overall LS-BMD and FN-BMD gr/cm2 in total patients were lower than in controls by 6 % (p = 0.065) and 5.9 % (p = 0.09), respectively. In patients <50 years, mean LS-BMD gr/cm(2) was lower than controls by 11.3 % (p = 0.013) and FN-BMD by 8.8 % (p = 0.044). Mean BMD T-score and BMD Z-score in both measurement sites were also lower than controls (p = 0.013 and 0.01, respectively. Frequency of osteoporosis did not differ but frequency of patients with BMD Z-score <-1 was significantly higher in patients (odds ratio (OR) = 6.57 95 % CI, 1.8-23.9, p = 0.004). In age group ≥50 years old, reduction of BMD in both measurement sites did not reach to a significant level.

CONCLUSION

This study indicates that BMD reduction in ICS user with asthma is dependent on age and appears that younger patients are at greater risk of BMD loss. These findings suggest preventive measures particularly in patients <50 years.

Are asthmatic patients prone to bone loss?

BACKGROUND

Recent studies suggest an association between allergic diseases, including asthma, and lower vitamin D level, a well-known risk factor of osteoporosis. However, it is not yet clearly known whether patients with asthma are prone to bone loss.

OBJECTIVE

To evaluate whether the occurrence of airway hyperresponsiveness (AHR) or asthma is related to significant changes in bone mineral density (BMD).

METHODS

We retrospectively enrolled 7,034 patients who had undergone a health checkup program, including BMD tests and methacholine bronchial challenge tests, at the Seoul National University Hospital, Healthcare System Gangnam Center, from November 1, 2004 to April 30, 2011. Asthma was ascertained by self-reported medical diagnosis by a physician. Patients with a history of systemic corticosteroid medication use were excluded from the study.

RESULTS

Among a total of 7,034 patients, 216 (3.1%) had a positive AHR test result, and 217 (3.1%) had a history of asthma. Lumbar spine and femur BMD of patients with AHR were significantly lower than those without AHR (-0.53 ± 1.50 vs -0.03 ± 1.49, -0.47 ± 0.97 vs -0.22 ± 0.99, respectively; P < .001 for both). After being adjusted for age, sex, body mass index, smoking status, postmenopausal state, and previous history of hormone replacement therapy, the proportion of patients with osteopenia or osteoporosis was much higher in the AHR-positive group than in the AHR-negative group (odds ratio, 1.715; 95% confidence interval, 1.252-2.349) and in the ever-asthma group than in the never-asthma group (odds ratio, 1.526; 95% confidence interval, 1.120-2.079).

CONCLUSION

In the current study, AHR and asthma were related to clinically meaningful BMD decrease, although the causal relationship is unclear.

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.

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.

Effect of long-term corticosteroid use on bone mineral density in children: a prospective longitudinal assessment in the childhood Asthma Management Program (CAMP) study

OBJECTIVE

Systemic corticosteroids are known to induce osteoporosis and increase the risk for fractures in adults and children. Inhaled corticosteroids have been shown to increase the risk for osteoporosis and fractures in adults at risk; however, long-term prospective studies of children to assess risks of multiple short courses of oral corticosteroids and chronic inhaled corticosteroids have not been performed. Thus, we assessed the effects of multiple short courses of oral corticosteroids and long-term inhaled corticosteroids on bone mineral accretion over a period of years.

METHODS

This was a cohort follow-up study for a median of 7 years of children who had mild-to-moderate asthma and initially were randomly assigned into the Childhood Asthma Management Program trial. Serial dual-energy radiograph absorptiometry scans of the lumbar spine for bone mineral density were performed for all patients. Annual bone mineral accretion was calculated for 531 boys and 346 girls who had asthma and were aged 5 to 12 years at baseline (84% of the initial cohort).

RESULTS

Oral corticosteroid bursts produced a dosage-dependent reduction in bone mineral accretion (0.052, 0.049, and 0.046 g/cm(2) per year) and an increase in risk for osteopenia (10%, 14%, and 21%) for 0, 1 to 4, and >or=5 courses, respectively, in boys but not girls. Cumulative inhaled corticosteroid use was associated with a small decrease in bone mineral accretion in boys but not girls but no increased risk for osteopenia.

CONCLUSIONS

Multiple oral corticosteroid bursts over a period of years can produce a dosage-dependent reduction in bone mineral accretion and increased risk for osteopenia in children with asthma. Inhaled corticosteroid use has the potential for reducing bone mineral accretion in male children progressing through puberty, but this risk is likely to be outweighed by the ability to reduce the amount of oral corticosteroids used in these children.

Effect of inhaled corticosteroids on forearm bone mineral density: the HUNT study, Norway

PURPOSE

To study the effect of inhaled corticosteroid (ICS) on bone mineral density (BMD) in an observational longitudinal study.

METHODS

In 1995-97, as part of the Nord-Trøndelag Health Study, Norway, 10,941 subjects aged 20 yr or more, either reporting asthma diagnosis/asthma-related symptoms or randomly selected, were interviewed, underwent spirometry and had their forearm BMD assessed. Among these, 4705 persons were invited to follow-up interview and bone densitometry in 2001; a total of 2848 subjects were eligible for analyses.

RESULTS

Use of corticosteroids for respiratory diseases was reported by 1262 subjects, and 528 subjects had used ICS at both baseline and follow-up. The yearly loss of adjusted forearm distal BMD was higher in those reporting use of ICS at both baseline and follow-up compared to subjects without respiratory symptoms. In women the figures were 3.14 versus 2.26 mg/cm2, whilst in men they were 3.76 versus 1.92 mg/cm2 (both p<0.01). No significant association was found between loss of BMD and neither daily dose nor duration of ICS use. Reduced lung function (forced expiratory flow in 1s) was an independent risk factor for increased bone loss in both sexes.

CONCLUSIONS

ICS users had greater bone loss at the forearm compared to ICS naive persons, but no significant dose-response effect between ICS and BMD was found. Residual confounding by disease severity cannot be ruled out, but even in case of an ICS causal effect, this should have minor clinical significance in most patients using low to moderate doses of ICS.

Drug-Induced Musculoskeletal Disorders

Drug-induced musculoskeletal disorders represent a broad clinical spectrum, from asymptomatic biological abnormalities to severe and even life-threatening diseases. Since an increasing number of drugs have been implicated in inducing rheumatic symptoms and/or syndromes, this review is not meant to be exhaustive, bearing in mind that the development of any musculoskeletal disorder should be considered as possibly related to a medication. The purpose of this article is to provide an overview of the more frequent drug-induced musculoskeletal disorders. These include: (i) arthralgias and arthropathies, including chondropathies and inflammatory arthritis; (ii) connective tissue diseases, especially lupus-like syndromes; (iii) periarticular disorders, including tendinopathies, enthesopathies and frozen shoulder; (iii) bone diseases, such as osteoporosis, osteomalacia and osteonecrosis; and (iv) myopathies. Although virtually all drug classes may induce musculoskeletal disorders, a significant part of them are related to corticosteroids, vaccines, antibacterials and lipid-lowering agents. Knowledge of drug-induced musculoskeletal disorders avoids carrying out unnecessary investigations, and allows optimal management of the patients, i.e. early discontinuation of the offending agent, adequate treatment monitoring and/or intervention with appropriate preventive actions.

Effect of inhaled corticosteroids on risk of development of cataract: a meta-analysis

The objective of this study was to quantify the risk of cataract among users of inhaled corticosteroids (ICS). Studies that examined the association of ICS use with risk of cataract were identified through computerized (MEDLINE, EMBASE), manual searches using Index Medicus, and checking cross-references to recover all published articles and scientific session abstracts. Pooled odds ratio (OR) with 95% confidence intervals (CI) were estimated using two methods, fixed effects Mantel-Haenszel model and random effects DerSimonian-Laird model. Four studies satisfied all the inclusion/exclusion criteria and were included in the analysis. The pooled OR (95% CI) by the Mantel-Haenszel method was 1.48 (1.39-1.57) and by the DerSimonian-Laird method was 1.48 (1.30-1.68). The test for heterogeneity was not significant. A total number of nine negative studies would be required to make the results of our meta-analysis non-significant. Number needed to harm is 16 with 95% CI of 13-19. Contrary to popular belief, inhaled ICS may be associated with systemic side effects like cataract as shown by this meta-analysis. The risk of increased cataract shown in our analysis needs to be weighted against the benefits of ICS. Further evaluations are required to clarify the causal association between the dosage and duration of drug use.

No association between inhaled corticosteroids and whole body DXA in postmenopausal women

PURPOSE

Postmenopausal women treated with corticosteroids are regarded as a high-risk group due to the effect of both natural bone loss and possible adverse effects of treatment with inhaled corticosteroids (IC).

OBJECTIVE

To compare bone mineral density (BMD) in postmenopausal women exposed only to IC (IC group, n = 106) with that of BMD in women not exposed to corticosteroids (n = 124) and women exposed to oral and/or intra-articular injections in addition to inhaled corticosteroids (OC group, n = 31). The women were recruited from a population-based prospective cohort study.

METHODS

Dual X-ray absorptiometry (DXA) technique was used to measure BMD in whole body, spine, pelvis and lower extremities. A health questionnaire and an interview about past and present medication use were used.

RESULTS

The mean duration and dose of IC were 9.5 +/- 4.5 years and 615 microg daily. Whole body BMD did not significantly differ between the IC group (1.103 g/cm(2)) and the unexposed group (1.087 g/cm(2)). Within the IC group, BMD stratified for cumulative dose of IC, duration or current dose above or below 800 microg did not differ. Z-score BMD for tertiles did not differ when comparing the IC and OC groups.

CONCLUSION

No difference in BMD was noted between postmenopausal women exposed to inhaled corticosteroids and unexposed controls nor was there any dose response relationship between inhaled corticosteroid therapy and BMD.

Pharmacologic characteristics and adrenal suppression with newer inhaled corticosteroids: A comparison of ciclesonide and fluticasone propionate

BACKGROUND

Inhaled corticosteroids (ICSs) are the most potent anti-inflammatory choice for patients with asthma. Selecting the most appropriate ICS for a patient requires a thorough understanding of the pharmacologic properties of each drug.

OBJECTIVE

This review details the pharmacologic properties of ciclesonide (CIC) and fluticasone propionate (FP) and reviews the available data on suppression of the hypothalamic-pituitary-adrenal axis as a measure of systemic exposure and safety profile.

METHODS

Clinical studies and case reports were identified through a MEDLINE and EMBASE search of English-language articles. The databases were searched for the years 1990 to April 2005 using the terms ciclesonide, fluticasone, ICS, and adrenal suppression. All studies were clinical trials of pharmacologic properties of the ICSs in humans.

RESULTS

A total of 1082 articles were identified. CIC and FP are 2 of the most potent ICSs. Both have high receptor-binding affinities (12 times and 18 times that of dexamethasone, respectively), and both may provide enhanced respiratory effects through a prolonged pulmonary residence time. The CIC metered dose inhaler dispenses smaller and more highly respirable particles than FP (1.1-2.1 pm vs 2.8-3.2 microm, respectively). Therefore, a greater percentage of administered CIC is topically deposited in the lungs (52% vs 12% to 13% for FP). CIC is delivered as an inactive parent compound, which is converted to its active metabolite, desisobutyryl-CIC (des-CIC), by esterases in the airways. More than 50% of a dose of CIC is deposited and distributed evenly throughout the lungs of healthy adults; lipid conjugation in the lung also may increase lung residence time. On entering the systemic circulation, both corticosteroids are rapidly cleared by the liver (elimination half-life of 3.5 hours for CIC vs 7.8 hours for FP). However, plasma protein binding is greater with CIC/des-CIC (99%/ approximately 99%) than FP (90%), resulting in reduced amounts of des-CIC (<I%) versus FP (10%) circulating free in the plasma. Although studies of low or medium doses of FP have produced conflicting results, high doses of FP (>660 pg/d) may result in adrenal suppression. CIC has not been reported to produce any significant adrenal suppression throughout its studied dose range (up to 1280 micro/d).

CONCLUSIONS

A review of the literature suggests that CIC, as compared with FP, achieves greater pulmonary deposition, causes fewer adverse oropharyngeal effects, deposits less biologically active drug in the systemic circulation, and has less potential for adrenal suppression.

Concerns about intranasal corticosteroids for over-the-counter use: position statement of the Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology

The Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology was charged with formulating a position paper regarding the potential release of intranasal corticosteroids for over-the-counter use. We took the position that safety issues regarding this proposal would be our sole concern. We reviewed the literature to evaluate the frequency and severity of potential adverse events related to the administration of intranasal corticosteroids. We limited this review to 5 areas: (1) effects on growth, (2) ocular effects, (3) effects on bone, (4) effects on the hypothalamic-pituitary-adrenal axis, and (5) local adverse effects. After review of the available data, we concluded that intranasal corticosteroids should remain prescription-only drugs. Patients receiving an intranasal corticosteroid should be instructed in its use and that use should be monitored by a physician or an appropriately trained medical provider (eg, nurse practitioner or physician assistant) under the direct supervision of a physician. This conclusion was reached based on the evidence that corticosteroids administered by any route, including the intranasal route, have the potential to cause adverse effects in all the areas noted herein. Our conclusion was strengthened by the fact that these adverse effects can be insidious and therefore not evident for many years; there is the potential for overuse; patients could also have access to other forms of topically administered corticosteroids, thus increasing their total dose; and individuals vary in their susceptibility to corticosteroid-induced adverse effects. We were also influenced to take this position knowing that generally reassuring data regarding the use of respiratory tract-administered corticosteroids are based on mean data and that all such studies have shown outliers in whom adverse effects were evident. Thus, as stated, we recommend that intranasal corticosteroids remain prescription-only drugs.

Women with asthma: a review of potential variables and preferred medical management

OBJECTIVES

To summarize the potential variables that contribute to the increased risk of asthma in women, outline therapeutic strategies that address these variables, and review current treatment recommendations for both pregnant and nonpregnant women with asthma.

DATA SOURCES

Literature searches (MEDLINE and cross-references) were performed using the keywords asthma and women in combination with the terms compliance, depression, emergency department, hormones, menstruation, mortality, National Asthma Education and Prevention Program, osteoporosis, pregnancy, prevalence, smoking, and treatment. Searches were limited to human studies with data published before 2005.

STUDY SELECTION

The author selected relevant articles for inclusion in this review.

RESULTS

Fluctuations in sex hormones, menstruation, pregnancy, obesity, depression, medication nonadherence, and smoking may contribute to increased asthma symptoms or severity in women. Asthma control may be improved if physicians address conditions and behaviors associated with asthma variability and severity in women. Notably, asthma must be managed aggressively in pregnant women, because uncontrolled asthma can lead to perinatal complications. Asthma treatment in women is optimized through patient and physician adherence to national guideline recommendations, including provision of patient education and asthma action plans.

CONCLUSIONS

Multiple variables throughout the female life cycle may influence asthma control. Successful asthma management requires an ongoing partnership between the patient and her physician to address physiologic (eg, sex hormones, pregnancy, obesity, depression) and nonphysiologic (eg, smoking, medication nonadherence) factors that may contribute to decreased asthma control.

Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).

The role of nebulized inhaled corticosteroid therapy in adult patients with asthma and chronic obstructive pulmonary disease

Conventional metered-dose inhalers and dry powder inhalers are used by most adult patients with asthma and chronic obstructive pulmonary disease who receive inhaled corticosteroid therapy. There are circumstances, however, in which nebulized inhaled corticosteroid delivery may provide greater clinical benefit to these patients. This review discusses the efficacy and safety of nebulized inhaled corticosteroid therapy in adult patients with asthma or chronic obstructive pulmonary disease for whom nebulized therapy may be preferable.

Effects of inhaled corticosteroids on bone

OBJECTIVE

To discuss the effects of inhaled corticosteroids on bone and their potential public health implications.

DATA SOURCES

The MEDLINE and EMBASE databases were searched to identify articles published between 1966 and January 2004 with the following keywords in the title: inhaled corticosteroid, beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone plus bone, fracture, osteoporosis, osteocalcin, growth, or height.

STUDY SELECTION

Key studies of adequate size and duration that allowed for potential confounding factors where required were selected.

RESULTS

Inhaled corticosteroids are absorbed into the systemic circulation and therefore have the potential to cause adverse effects on bone. Several of the larger studies showed that inhaled corticosteroids cause a dose-related reduction in bone mineral density. Three cross-sectional studies found a dose-related increase in fractures in people taking an inhaled corticosteroid compared with controls. Prospective studies found a short-term reduction in growth velocity in children taking an inhaled corticosteroid, although target adult height is usually achieved.

CONCLUSION

Since osteoporotic fracture is common in elderly patients and up to 5% of the population in more developed countries take an inhaled corticosteroid, these findings have public health implications. Strategies are needed to reduce the systemic effects of inhaled corticosteroids.

Airway function in women: bronchial hyperresponsiveness, cough, and vocal cord dysfunction

Bronchial hyperreactivity and cough are common medical problems that occur more frequently in women. Differences in size, hormonal effects, density, and sensitivity to receptors and psychologic factors may all play a role, which results in increased expression of upper and lower airway disease. The reason that VCD occurs more commonly in women is not clear but many of the same explanations regarding bronchial hyperreactivity and cough may apply.

Impact of long-term inhaled corticosteroid therapy on bone mineral density: results of a meta-analysis

BACKGROUND

The impact of long-term inhaled corticosteroid (ICS) therapy on bone mineral density (BMD) is poorly understood.

OBJECTIVE

To evaluate the impact of long-term ICS use on BMD.

METHODS

Random-effects meta-analysis. Published and unpublished literature were identified by searches of MEDLINE and EMBASE databases and consultation with experts. Studies reporting BMD among adult asthma and chronic obstructive pulmonary disease (COPD) patients using ICS and non-ICS controls were identified. Studies selected for review included at least 1 year of follow-up. Two independent reviewers evaluated studies; data from those meeting specified inclusion criteria were abstracted for inclusion in the meta-analysis.

RESULTS

Fourteen (5.3%) of 266 reviewed studies met specified inclusion criteria. Sufficient data were available to perform meta-analysis on 3 measures for ICS-using patients (lumbar, femoral neck, and major trochanter BMD) and 1 measure (lumbar BMD) for non-ICS-using controls. Using current National Asthma Education and Prevention Program definitions, the majority of studies (12 of 14) included patients receiving moderate to high doses of ICSs. Among ICS users, annual changes from baseline in lumbar, femoral neck, and major trochanter BMD (-0.23%, -0.17%, and +1.46%, respectively) were not statistically significant. Mean changes in lumbar BMD were also not significantly different from controls (-0.02%). Further, annual changes in lumbar BMD were not statistically significant for subgroups of patients with asthma or COPD.

CONCLUSIONS

Long-term use of ICSs in patients with asthma or COPD was not associated with significant changes in BMD.

Review of the unique properties of budesonide

BACKGROUND

The aim of inhaled corticosteroid (ICS) therapy for asthma is to attain high therapeutic activity in the airways while keeping the risk of systemic adverse effects relatively low. However, the physicochemical and pharmacokinetic properties of various ICSs affect this ratio, thereby influencing their ability to fulfill the requirements of an ideal agent.

OBJECTIVE

This article reviews the physical and pharmacokinetic properties of budesonide, outlining how they, safety data, and use of different inhalation devices enable budesonide to meet many of the clinical requirements of an ideal ICS for the treatment of asthma.

RESULTS

ICS efficacy is influenced by lipophilicity, lung deposition, and retention in airway tissue, whereas the rate of elimination determines systemic activity. Budesonide is retained in the airways to a greater extent than other ICSs because of an esterification process that increases its lipophilicity. The prolonged retention of budesonide in the airways may contribute to its efficacy when administered QD. In addition to a pressurized metered-dose inhaler, budesonide is available as a dry-powder inhaler and in nebulized form, which can be used by asthma patients aged > or =6 months.

CONCLUSIONS

When combined with delivery devices suitable for a spectrum of patient groups, the physical and pharmacokinetic properties of budesonide lend it many of the characteristics of an ideal ICS, including favorable efficacy and tolerability profiles.