osteoporosis and inhaled steroids

Last edited 08/2020 and last reviewed 11/2020

There is some evidence that high doses of inhaled corticosteroids (ICS) (>2000 microgrammes/day) may result in significant osteoporosis over a period of several years (1).

• a large study has investigated the use of ICS and bone mineral density
  • total of 65 225 adults participated in a cross-sectional study in the Nord-Trøndelag Health Study 1995-1997 (2). Those reporting asthma or asthma-related symptoms, were invited to have bone densitometry of the forearm, flow volume spirometry and a personal interview.
  • altogether 4482 women and 4142 men participated, of whom 2113 reported ever use and 6511 never use of ICS
  • bone mineral density (BMD) of the forearm was compared between 2113 users and 6511 never users of inhaled corticosteroid (ICS)
    • compared to never-users, users of ICS alone or combined with courses of prednisolone had 1.6% lower BMD and users of prednisolone >= 6 months had 7.7% lower BMD both at the distal and ultradistal site
    • no dose-response association was found between daily dose, duration of use or cumulative dose of ICS and BMD
      • study authors noted that lack of dose response between ICS and BMD in the present study could be due to a narrow range of doses in this population, as only 10% of ICS users reported daily doses >=900 microgrammes/day

A large general practice-based cohort study (3) in the UK involving 1,183,663 women and 1,174,234 men showed that people with a history of asthma had an increased risk of fracture. The adjusted hazard ratio was 1.29 (95% CI 1.22 to 1.36) for any fracture and 1.32 (95% CI 1.21 to 1.44) for hip fracture in women and similar in men.

People over the age of 50 with asthma may be considered for fracture-risk assessment, particularly in the presence of other risk factors (4).

Reference:

• 1) Wong, CA, Walsh, LJ et al. Inhaled corticosteroid use and bone-mineral density in patients with asthma. Lancet 2000;355:1399-403.
• 2) Langhammer A et al. Use of inhaled corticosteroids and bone mineral density in a population based study: the Nord-Trøndelag Health Study (the HUNT Study). Pharmacoepidemiology and Drug Safety 2004;13 (8): 569-579
• 3) Hippisley-Cox J, Coupland C. Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores.
  BMJ 2009;339:b4229.
• 4) SIGN (June 2020). Management of osteoporosis and the prevention of fragility fractures