Nottingham, UK—Asthma patients need to be aware that their use of steroid inhalers or tablets to treat their condition or control flare-ups puts them at greater risk of osteoporosis and fragility fractures (FF).

That is according to a UK study published in the journal Thorax. University of Nottingham–led researchers also determined that risks increase with higher cumulative doses and longer treatment periods.

The researchers point out that while inhaled (ICS) and oral (OCS) corticosteroids are used widely in asthma, the likelihood of osteoporosis and FF in those patients has not been well established.

In response, the study team conducted two nested case-control studies using linked data from the Clinical Practice Research Datalink and Hospital Episode Statistics databases using data from April 2004 to December 2017. The study, using an asthma cohort, separately identified patients with osteoporosis or FF and gender-, age- and practice-matched controls. The goal was to determine the association between ICS and OCS exposure, and the risk of osteoporosis or FF. Also calculated was the prevalence of patients receiving at least one bisphosphonate.

Researchers report a dose–response relationship between both cumulative dose and number of OCS/ICS prescriptions within the previous year, and risk of osteoporosis or FF.

In fact, after adjusting for confounders, patients receiving more OCS prescriptions (≥9 vs. 0) had a 4.50 (95% CI, 3.21-6.11) and 2.16 (95% CI, 1.56-3.32) increased risk of osteoporosis and FF, respectively. Odds ratios for ICS (≥11 vs. 0) were 1.60 (95% CI, 1.22-2.10) and 1.31 (95% CI, 1.02-1.68) for the two conditions, respectively. The authors also point out that cumulative dose had a similar impact, with those receiving more OCS or ICS being at greater risk.

Yet, the study notes, the prevalence of patients taking ≥9 OCS and at least one bisphosphonate prescription was just 50.6% and 48.4% for osteoporosis and FF, respectively.

“The findings suggest that exposure to OCS or ICS is an independent risk factors for bone health in patients with asthma,” the researchers conclude. “Steroid administration at the lowest possible level to maintain asthma control is recommended.”

Based on study results, two to three steroid-tablet prescriptions in the preceding 12 months appeared to increase the osteoporosis, with those receiving nine or more prescriptions and cumulative doses of 2,500 mg or more having more than four times the risk of those who were not prescribed these drugs. Those patients also were more than twice as likely to sustain an FF.

In addition, patients provided 11 or more prescriptions for inhaled steroids were 60% more likely to have osteoporosis and 31% more likely to have FF than those who were not prescribed the drugs, according to the report.

One concern, the authors note, is that only about half of patients prescribed steroid tablets and even fewer prescribed steroid inhalers were prescribed bisphosphonates in the year leading up to a diagnosis of osteoporosis or FF. “Current guidelines on asthma do not fully cover the management of bone comorbidities and no specific bone protection guidance is given. Our results suggest that risk and prevention of osteoporosis and [fragility fractures] should be addressed explicitly in future guideline updates,” they add.

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