Oral or inhaled corticosteroids increase osteoporosis risk

Oral and inhaled corticosteroids are independent risk factors adversely affecting bone health in asthma patients, researchers found.

Two case-controlled studies determined that there is a dose-response relationship between the cumulative dose and number of oral (OCS) and inhaled corticosteroid (ICS) prescriptions received by patients and the risk of osteoporosis and fragility fracture.

The researchers, led by Christos V. Chalitsios, BSc, MSc, University of Nottingham, Nottingham, United Kingdom, concluded that the use of OCS and ICS “should be kept to the minimum necessary to treat symptoms and should be stepped down if symptoms and exacerbations are well managed.”

Their results were published in Thorax.

As noted by Chalitsios and colleagues, asthma is a common condition, affecting hundreds of millions of people worldwide. While both OCS and ICS play vital roles in controlling airway inflammation in these patients, they are known to cause side effects, particularly osteoporosis.

The authors also pointed out that the use of ICS is likely to increase given that Global Initiative for Asthma (GINA) guidelines recommend combined long-acting-β2 -agonists with ICS at step 1, and there has been an upward trend in prescribing of OCS for patients with severe asthma or patients who are experiencing exacerbations.

Thus, Chalitsios and colleagues wanted to confirm the link between oral and inhaled steroids and osteoporosis and fragility fractures (FF) in asthma patients by stratifying risk according to dose, number of courses taken, and type of steroid.

The authors conducted two nested case-control studies using linked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases, with cases defined by the first-recorded diagnosis of osteoporosis and fragility fractures as separate outcomes.

Their analyses included 1,564 patients with asthma and osteoporosis and 3,313 control subjects, and 2,131 patients with asthma and fractures and 4,421 control subjects, respectively.

These analyses were adjusted for variables known to have an impact on osteoporosis or fracture, including age, sex, BMI, smoking and alcohol status, socioeconomic status, osteoporosis (only when the outcome was FF), any fracture (not those considered as an outcome) or falls prior to index date, and bisphosphonates, vitamin D, and calcium supplements in the year prior the index date.

They found that there was a dose-response relationship between both dose and cumulative steroid prescriptions within the previous year and the risk of osteoporosis and FF.

Specifically, after adjusting for confounders, Chalitsios and colleagues found that as patients received more OCS prescriptions, their risk of osteoporosis increased, with those receiving 9 or more prescriptions being at greater risk (aOR 4.50, 95%CI 3.21 to 6.11). While ICS exposure was also associated with an increased risk of osteoporosis, the effect was weaker, with patients having 11 or more prescriptions 1.6 times more likely to be diagnosed with osteoporosis than controls (aOR 1.60, 95%CI 1.22 to 2.10).

OCS also had an effect on the risk of FF, although less than that on osteoporosis. Patients with nine or more OCS prescriptions were more than two times more likely to be diagnosed with osteoporosis than controls (≥9 vs 0 prescriptions; aOR 2.16, 95% CI 1.56 to 3.38), while 11 or more ICS prescriptions were also associated with an increased risk of fracture (≥11 vs 0 prescriptions; aOR 1.31, 95% CI 1.02 to 1.68).

Patients also receiving a greater cumulative dose of OCS or ICS were at greater risk of developing osteoporosis or experiencing FF.

Chalitsios and colleagues also found that the prevalence of OCS users receiving at least one bisphosphonate prescription was 31.4% for osteoporosis and just 21.4% for FF. In addition, only about half of patients who received 9 or more OCS prescriptions had at least one bisphosphonate prescription.

“The low percentage of bisphosphonate use after the first OCS prescription in the year prior the osteoporosis or FF diagnoses is disappointing as this class of drugs is considered the most effective bone protective agent,” the authors observed.

They also noted that asthma guidelines do not currently cover the management of bone comorbidities or provide specific bone protection guidance. Therefore, they suggested this study “using primary and secondary care data provides pragmatic guidance to clinicians by stratifying bone health risk by dose, number of prescriptions, and type of OCS and ICS.”

  1. There is a dose-response relationship between the number of oral and inhaled corticosteroid prescriptions received by asthma patients, as well as cumulative dose, and the risk of osteoporosis and fragility fracture.

  2. Use of oral and inhaled corticosteroids should be kept to the minimum necessary to control exacerbations.

Michael Bassett, Contributing Writer, BreakingMED™

Chalitsios had no disclosures.

Cat ID: 195

Topic ID: 89,195,192,195,63,925