The higher the cumulative dose and the longer the duration of treatment, the greater the risk appears to be — ScienceDaily

Taking steroid inhalers or tablets to treat asthma or control flare-ups is linked to an increased risk of brittle bones (osteoporosis) and increased susceptibility to fractures (fragility fractures), according to research published in line in the magazine Thorax.

The higher the cumulative dose and the longer the duration of treatment, the greater these risks appear to be, the results indicate.

Asthma is common and affects approximately 334 million people worldwide. And steroid inhalers and tablets are widely used to reduce airway inflammation and prevent and/or relieve asthma symptoms.

International guidelines recommend a staged approach to treating the condition, with steroid inhalers prescribed for moderate to severe disease control and steroid tablets for severe asthma flare-ups.

Research investigating the impact of steroids on bone health has so far been inconclusive. The researchers wanted to see if looking at dose, number of courses, and type of steroids separately could help shed more light on the matter.

This is particularly important as international guidelines have shifted towards greater use of inhaled steroids for moderately severe asthma, while the use of steroid tablets has also increased, say the researchers.

They relied on anonymized health records entered into the nationally representative Clinical Practice Research Datalink (CPRD) GOLD database. This covers over 15.4 million patients from 738 medical practices across the UK, equivalent to 7% of the UK population. And they relied on linked data from Hospital Episode Statistics (HES) for July 2018, which records all hospital admissions in England.

They used this data to identify all adults with asthma diagnosed between April 2004 and December 2017 who also had osteoporosis or fragility fractures. These patients were matched with at least four patients of the same age and sex from the same general practice, but who did not have osteoporosis or fragility fractures.

The researchers also checked whether the patients had received at least one dose of bisphosphonates – a type of drug used to halt bone density loss and prevent osteoporosis – and bone-strengthening vitamin D and calcium supplements.

Records were searched for other factors that may affect bone density, including smoking, weight, and alcohol consumption.

The number of prescriptions filled was used to determine the amount and duration of steroid treatment for the 12 months preceding a diagnosis of osteoporosis or fragility fracture.

Analysis of all data showed a clear association between cumulative dose and number of courses of inhaled or steroidal tablets and the risk of osteoporosis or fragility fractures.

Two to three prescriptions of steroid tablets in the previous 12 months were associated with a higher risk of osteoporosis: people who received 9 or more prescriptions and cumulative doses of 2500 mg or more had more than 4 times more risks than those who were not prescribed these drugs, after accounting for potentially influencing factors. They were also more than twice as likely to sustain a fragility fracture.

Similarly, people who received 11 or more prescriptions for inhaled steroids were 60% more likely to have osteoporosis and 31% more likely to have fragility fractures than those who did not receive these drugs.

Patients who received cumulative doses of more than 120 mg in the previous year were 20% more likely to suffer a fragility fracture.

Only about half of patients prescribed steroid tablets and even fewer prescribed steroid inhalers were prescribed bisphosphonates in the year before a diagnosis of osteoporosis or fragility fracture, a finding that the researchers call it “disappointing”.

But they point out: “Current asthma guidelines do not fully cover the management of bone comorbidities and no specific recommendations for bone protection are given. Our results suggest that the risk and prevention of osteoporosis and [fragility fractures] should be addressed explicitly in future guideline updates. »

This is an observational study, and as such cannot establish cause. And researchers acknowledge that inhalers can be difficult to use correctly, which may underestimate the actual dose taken. Their analysis was also based on requirements and not actual compliance.

Nevertheless, they conclude: “Both [oral] and [inhaled] steroids are associated with an increased risk of osteoporosis and [fragility fracture] in people with asthma. The use of [these drugs] should be kept to the minimum needed to treat symptoms and should be reduced if symptoms and exacerbations are well managed. »

And they add that physicians should consider additional bisphosphonate therapy to protect patients’ bone health.

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Materials provided by BMJ. Note: Content may be edited for style and length.