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The papers recently published in Thorax by Tattersfield et al1 and Walsh et al2 offer important information about the possible adverse affects of corticosteroids on bone mineral density (BMD). Tattersfield and her colleagues reported no change in BMD with inhaled corticosteroids for mild asthma, while Walsh et al found a dose related increase in the incidence of fractures in those taking oral corticosteroids. We would like to report our study of BMD in patients with airways disease, which reinforces these findings and highlights men as being particularly at risk.
We prospectively studied 100 consecutive outpatients (44 men) with steroid responsive airways disease. The formulation and cumulative dose of corticosteroid was recorded in each individual, together with all prescribed prophylaxis for osteoporosis. Bone mineral density was measured in the non-dominant forearm. We found no relationship between inhaled corticosteroid dose and BMD. Mean BMD was significantly reduced in those on oral as opposed to inhaled steroids. In men the mean Z scores for those on inhaled and oral corticosteroids were 0.1 and –0.6, respectively (p=0.07), while women had mean Z scores of 0.5 and –0.3 for inhaled and oral corticosteroids, respectively (p=0.016). Our patient numbers were insufficient to confirm a dose response. The surprising result was that men were more likely to meet the WHO criteria for osteoporosis than women (25% v 12.5%). This result is explained at least in part by the use of prophylaxis which was prescribed to 21 women but to only two men. Of those on regular oral steroids, only 5.5% of men received prophylaxis compared with 62.5% of women. Similar results have been reported in other chronic diseases, with a greater reduction in BMD being reported in men with cystic fibrosis.3
Unfortunately it appears to have been assumed that men are protected from osteoporosis by virtue of their gender. When chronic disease is treated with oral corticosteroids, both men and women are equally at risk of osteoporosis and all should be considered for prophylaxis.