Osteoporosis in the at-risk asthmatic

Abstract

The effect of inhaled glucocorticosteroids (ICS) on bone metabolism and subsequent osteoporosis is controversial. Explanations for this controversy include various study designs, duration of use, outcome measures, and population demographics of research studies with intranasal or inhalational ICS. Patients with poorly controlled asthma are at greatest risk of osteoporosis because they are commonly treated with intermittent or continuous systemic corticosteroids (SCS) or high-dose ICS. A 45-year-old Caucasian woman presents with moderate-to-severe asthma with frequent albuterol use and nighttime awakenings at least once weekly. She is on fluticasone/salmeterol 500/50 μg one inhalation twice daily and montelukast 10 mg/day. She requires prednisone 15 mg three times per day for 5 days up to three times a year. Is this patient at greater risk of osteopenia, characterized by a T-score between -1.0 and -2.5, and subsequent osteoporosis and an increased risk of fractures? If she has osteopenia, should she be treated with a bisphosphonate? The risk of osteoporosis and fracture increases significantly with frequent administration of SCS, and patients on such medications should undergo preventative measures and treatment. This study discuses factors that contribute to an increased risk of osteoporosis/osteopenia in patients with asthma and suggests recommendations based on the current literature.

Quantitative Ultrasound Measurement at the Hand Phalanges Does Not Reveal Skeletal Disturbances in Children With Bronchial Asthma: A Longitudinal Observation

“…Paradoxically, the total exposure of an organism to glucocorticosteroids is higher, and additionally, oral administration determines the greater toxicity of treatment. This issue was indicated and discussed by Aljubran et al 30 as well as Fuhlbrigge and Kelly. 31 Another important aspect related to impairment of the skeletal status in patients with asthma is vitamin D metabolism.…”

Does Allergy Break Bones? Osteoporosis and Its Connection to Allergy

“…The association of osteoporosis with asthma is known, but in the past, most studies mainly focused on the bone adverse effects of prolonged corticosteroid treatments [67,68]. Recent studies have emphasized the role of the systemic inflammatory response to the chronic lung inflammatory disease in the development of osteoporosis, as the pivotal role of inflammatory mediators in this condition is well known.…”

Inhaled Corticosteroids and Bone Health

“…However, because of the adverse cardiovascular effects the drug is used only if the benefits on bone disease outweigh the potential risk. Selective estrogen receptor modulators (SERMs) such as raloxifene, lasofoxifene and bezedoxifene are useful as second-line agents in postmenopausal women with osteoporosis who are unsuitable candidates for the use of bisphosphonate [ 66 ]. Newer agents such as romosozumab (a monoclonal antibody against sclerostin that interferes with osteoblast function) are emerging as promising tools in the therapeutic armamentarium against osteoporosis [ 66 , 67 ].…”

“…The ACR recommendations on management of GIO can be applied to high risk patients on ICS treatment. The FRAX tool can be used to calculate the risk, although this scoring system is not applicable to premenopausal women and men aged <50 years [ 66 ]. An algorithm for the evaluation and management of bone disease in ICS users is shown in the Fig.…”