ArticlesInhaled corticosteroid use and bone-mineral density in patients with asthma
Introduction
Inhaled corticosteroids are highly effective in the treatment of asthma, and are often required for long-term control. One in three asthmatic patients in the UK takes an inhaled corticosteroid regularly, and a third are prescribed 800 μg or more per day.1 Administration of a corticosteroid by inhalation enables it to be targeted to the airways with substantially fewer adverse effects than by the oral route.2 Nevertheless, inhaled corticosteroids are absorbed into the systemic circulation from the lung, and more variably from the gastrointestinal tract,2 and their use has been associated with bruising,3 cataracts,4 and glaucoma.5 Whether and to what extent they have clinically important effects on bone is uncertain. Because inhaled corticosteroids are widely prescribed, and because osteoporotic fracture is common, a small increase in the relative risk of osteoporosis would have important public-health implications.
Studies investigating the association between inhaled corticosteroid use and bone-mineral density in adults have given inconsistent results.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 These studies have been small, the duration of treatment has been short, and most have been confounded by patients' previous use of oral corticosteroids. We therefore tested the hypothesis that there is a relation between cumulative inhaled corticosteroid use and bone-mineral density at the lumbar spine in a much larger group of patients with little prior use of oral corticosteroids; we also aimed to quantify the relation after allowing for potential confounding factors. We restricted our study to patients aged 20–40 years to keep confounding by age and menopause to a minimum.
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Patients
Patients were recruited between April, 1996, and December, 1997, from 51 general practices in and around Nottingham, UK, that had at least a year's worth of computerised details of patients and prescriptions. The practices were identified by the Nottinghamshire and Derbyshire Family Health Service Associations, and those within 35 miles of Nottingham were invited to participate. Additional patients were recruited from our register of asthma-research volunteers provided that their general
Results
We studied 196 patients (119 women) of whom 176 were recruited from general practice and 20 from our volunteer database. Their median age was 32 years and mean FEV1 was 93% predicted (table 1). Median duration of treatment with an inhaled corticosteroid was 6 years (range 0·5–24), and the median cumulative dose was 876 mg (range 88–4380). At the time of recruitment, beclometasone dipropionate, budesonide, and fluticasone propionate were being taken by 157 (80%), 27 (14%), and 12 (6%) of the
Discussion
This large, cross-sectional survey looked at the relation between inhaled corticosteroid use and bone-mineral density in patients with asthma. We found a clear inverse relation between cumulative inhaled corticosteroid dose and bone-mineral density at the lumbar spine and proximal femur.
Our study was specifically designed to address some of the drawbacks associated with previous studies. By enrolling patients from a primary-care population, we obtained a much larger sample size, and by
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