Abstract
Many asthmatics today are treated with inhaled glucocorticoids. Oral steroids are known to accelerate bone loss and promote fracture, but it is not clear that the inhalational route has similar consequences; past studies have given inconsistent results. For this reason a 3-year prospective cohort study was performed in 109 premenopausal women 18 to 45 years of age who had asthma but no condition that causes bone loss. The participants had inhaled four or more puffs daily of glucocorticoid in the same dose for at least 6 weeks. All those not receiving triamcinolone acetonide were switched to this corticoid in a dose of 100 μg per puff. Bone density was measured by dual-photon absorptiometry at intervals for up to 3 years. Patients used a maximum of 28 puffs per day of inhaled glucocortoid. The average number of daily puffs correlated negatively with the yearly change in bone density, as measured both in the total hip and the trochanter. Each additional daily puff correlated with a yearly decline in bone density of 0.00044 g/cm 2 at these sites. There was, however, no significant association with declining bone density at the femoral neck and spine. The relation between bone density at the total hip and trochanter and the average daily puffs of inhaled steroid persisted after adjusting for the use of oral or parenteral glucocorticoids, concurrent use of nasal steroid, age, and oral contraceptive use. Neither the dose of inhaled glucocorticoid nor the decline in bone density correlated with urinary levels of N-telopeptide, calcium, or cortisol, or with serum levels of osteocalcin, calcium, cortisol, or parathyroid hormone. Higher inhaled doses of glucocorticoid correlated directly with small annual declines in bone density in the total hip and trochanter in these premenopausal women treated for asthma. This finding suggests using the lowest dose needed to control asthmatic symptoms. Periodic bone density measurements could indicate when prophylactic measures to protect skeletal integrity are appropriate.
Highlights
Inhaled glucocorticoids are the most commonly used medications for the long-term treatment of patients with asthma
It is known that oral glucocorticoid therapy accelerates bone loss, and fractures may occur in 30 to 50 percent of patients,[3,4] it is not clear whether inhaled glucocorticoids accelerate bone loss
The results of prospective and cross-sectional studies of the effects of inhaled glucocorticoids on bone have been inconsistent,[5,6,7,8,9,10,11,12,13,14,15] in that inhaled glucocorticoids have been associated with decreases in bone density in some studies and no change in bone density in others
Summary
Inhaled glucocorticoids are the most commonly used medications for the long-term treatment of patients with asthma. Whether long-term therapy with inhaled glucocorticoids reduces bone mass, as oral glucocorticoid therapy does, is controversial. In a three-year prospective study, we examined the relation between the dose of inhaled glucocorticoids and the rate of bone loss in premenopausal women with asthma. Methods We studied 109 premenopausal women, 18 to 45 years of age, who had asthma and no known conditions that cause bone loss and who were treated with inhaled triamcinolone acetonide (100 μg per puff). We measured bone density by dual-photon absorptiometry at base line, at six months, and at one, two, and three years. We measured inhaled glucocorticoid use by means of monthly diaries, supported by the use of an automated actuatormonitoring device
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