Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Loke, Yoon K.; Cavallazzi, Rodrigo; Singh, Sonal

doi:10.1136/thx.2011.160028

Cited by 240 publications

(156 citation statements)

References 23 publications

(29 reference statements)

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“…There is also much controversy about the negative impact of inhaled glucocorticoids on bone health. Inhaled glucocorticoids are certainly less detrimental to bone as compared to systemic glucocorticoids, although doses >800 mcg/day of budesonide (or equivalents) may be associated with accelerated bone loss and increased risk of fractures, especially with long-term use (24)(25)(26). It is important to remember that fracture risk in glucocorticoid-induced osteoporosis is much higher as compared to that expected based on DXA BMD values, and rapidly decreases after treatment discontinuation (27,28).…”

Section: Epidemiology and Clinical Manifestationsmentioning

confidence: 94%

Guidelines for the diagnosis, prevention and management of osteoporosis

et al. 2016

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Osteoporosis poses a significant public health issue. National Societies have developed Guidelines for the diagnosis and treatment of this disorder with an effort of adapting specific tools for risk assessment on the peculiar characteristics of a given population. The Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS) has recently revised the previously published Guidelines on the diagnosis, riskassessment, prevention and management of primary and secondary osteoporosis. The guidelines were first drafted by a working group and then approved by the board of SIOMMMS. Subsequently they received also the endorsement of other major Scientific Societies that deal with bone metabolic disease. These recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on leading experts' experience and opinion, and on good clinical practice. The osteoporosis prevention should be based on the elimination of specific risk factors. The use of drugs registered for the treatment of osteoporosis are recommended when the benefits overcome the risk, and this is the case only when the risk of fracture is rather high as measured with variables susceptible to pharmacological effect. DeFRA (FRAX® derived fracture risk assessment) is recognized as a useful tool for easily estimate the long-term fracture risk. Several secondary forms of osteoporosis require a specific diagnostic and therapeutic management

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Section: Epidemiology and Clinical Manifestationsmentioning

confidence: 94%

Guidelines for the diagnosis, prevention and management of osteoporosis

et al. 2016

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“…However its adverse effects, such as pneumonia and impairment in bone health, have long been a concern. Although the impact of ICS on bone density and fracture rate in prospective trials is controversial [27,28], a recent meta-analysis did show a modest but statistically significant increased likelihood of such risk [29]. The present study further heightens this concern when longterm occupational or environmental exposure to air pollution is taken into consideration.…”

Section: Discussionmentioning

confidence: 70%

Air Pollution Exposure and Osteoporosis among Retired Workers with Chronic Obstructive Pulmonary Disease

Lee¹,

Liu²,

Kuo

et al. 2014

Occup Med Health Aff

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Background: While effects of occupational and environmental air pollution exposure on inflammation-related cardiopulmonary impairment are well documented, the association linking long-term air pollution exposure and osteoporosis risk is still unclear. The aim of this study was to investigate effects of long-term air pollution exposure on the risk of osteoporosis in people with chronic obstructive pulmonary disease (COPD).

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“…This increase was due entirely to an increase in the risk of an upper extremity fracture, which increased by 12 % per each additional 1,000 lg of ICS per day in beclomethasone-equivalent units. By analyzing data from two previous meta-analyses [57,58], a very recent meta-review on adverse effects of ICS [25] concluded that ICS use was consistently associated with an increase in the risk of all types of fractures in patients with COPD, with an estimated number needed to treat for harm of 83 patients over 3 years of ICS use. Moreover, the dose-response relationship demonstrated that each 500 lg increase in beclomethasone dose equivalents was associated with a 9 % increase in risk of fractures, with modest overall effect size.…”

Section: Bone Fracturesmentioning

confidence: 99%

Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

et al. 2015

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Inhaled corticosteroids (ICSs) are widely used in the treatment of patients with chronic obstructive pulmonary diseases. However, high-dose regimens and longterm use of ICSs have the potential to cause a variety of local and systemic side effects such as candidiasis, cataracts, glaucoma, and osteoporosis. The use of ICSs can also be associated with the risk of bone fractures, diabetes mellitus and pneumonia. These ICS-related side effects are of particular importance in elderly patients due to the presence of comorbidities and age-related behavioral, cognitive, and psychological problems, which can all interact with inhaled treatment. We reviewed the available literature on the clinically relevant side effects of ICSs in the elderly to provide practical measures to properly monitor and manage the risk of ICSs in the geriatric population. Inspection of the mouth, monitoring of ocular pressure, and use of bone-protective drugs may be necessary in patients on prolonged ICS therapy. Above all, the use of the lowest possible ICS dose and a careful re-assessment of the inhalation procedure should be recommended. Taken together, these observations suggest that physicians should use ICSs appropriately for those patients in whom the benefit will outweigh the risk, especially chronic obstructive pulmonary disease (COPD) patients with previous frequent exacerbations. Given the paucity of information on the topic and the need to extrapolate the results from studies with broader age ranges, we strongly encourage the design of specifically tailored clinical studies in the elderly. Key PointsAsthma and chronic obstructive pulmonary disease (COPD) are inflammatory disorders of the airways. The pharmacological management of these chronic diseases is based on persistent and long-term use of inhaled corticosteroids (ICSs).Asthma and COPD are among the most common chronic diseases in clinical settings, and physicians are expected to diagnose and manage those diseases in the geriatric population on a daily basis. The management of chronic obstructive respiratory diseases in the geriatric population is complicated by the increased occurrence of comorbidities and associated treatment, and by age-associated physiological and structural changes of the lung.The chronic use of ICSs in the elderly is associated with the increased risk of local and systemic side effects such as candidiasis, cataract, glaucoma, diabetes mellitus, bone fractures, and pneumonia. Physicians should be aware of this in order to select those patients in whom the benefits will outweigh the risks.The online version of the original article can be found under

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Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies

Cited by 240 publications

References 23 publications

Guidelines for the diagnosis, prevention and management of osteoporosis

Guidelines for the diagnosis, prevention and management of osteoporosis

Air Pollution Exposure and Osteoporosis among Retired Workers with Chronic Obstructive Pulmonary Disease

Erratum to: Safety Considerations of Inhaled Corticosteroids in the Elderly

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