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Original research
Risk of osteoporosis and fragility fractures in asthma due to oral and inhaled corticosteroids: two population-based nested case-control studies
  1. Christos V Chalitsios1,
  2. Dominick E Shaw1,
  3. Tricia M McKeever2
  1. 1 School of Medicine, Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
  2. 2 School of Medicine, Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
  1. Correspondence to Christos V Chalitsios, School of Medicine, Division of Respiratory Medicine, University of Nottingham, Nottingham NG7 2RD, UK; christos.chalitsios{at}


Background Inhaled (ICS) and oral (OCS) corticosteroids are used widely in asthma; however, the risk of osteoporosis and fragility fracture (FF) due to corticosteroids in asthma is not well-established.

Methods We conducted two nested case-control studies using linked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. Using an asthma cohort, we separately identified patients with osteoporosis or FF and gender-, age- and practice-matched controls. Conditional logistic regression was used to determine the association between ICS and OCS exposure, and the risk of osteoporosis or FF. The prevalence of patients receiving at least one bisphosphonate was also calculated.

Results There was a dose–response relationship between both cumulative dose and number of OCS/ICS prescriptions within the previous year, and risk of osteoporosis or FF. After adjusting for confounders, people receiving more OCS prescriptions (≥9 vs 0) had a 4.50 (95% CI 3.21 to 6.11) and 2.16 (95% CI 1.56 to 3.32) increased risk of osteoporosis and FF, respectively. For ICS (≥11 vs 0) the ORs were 1.60 (95% CI 1.22 to 2.10) and 1.31 (95% CI 1.02 to 1.68). The cumulative dose had a similar impact, with those receiving more OCS or ICS being at greater risk. The prevalence of patients taking ≥9 OCS and at least one bisphosphonate prescription was just 50.6% and 48.4% for osteoporosis and FF, respectively.

Conclusions The findings suggest that exposure to OCS or ICS is an independent risk factors for bone health in patients with asthma. Steroid administration at the lowest possible level to maintain asthma control is recommended.

  • asthma
  • asthma epidemiology
  • asthma pharmacology

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  • Contributors CVC had full access to all the study data and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: CVC, DES, TMM; acquisition of data: CVC; analysis of data: CVC; interpretation of data: CVC, DES, TMM; drafting the article: CVC; revision for important intellectual content and approval of the version to be published: CVC, DES, TMM.

  • Funding The study was funded by a research award from the British Medical Association (BMA).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. This study is based on Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data and is subject to a full license agreement which does not permit data sharing outside of the research team. However, data can be obtained by applying to CPRD ( for any replication of the study.The Read and ICD-10 codes used are available from the corresponding author upon reasonable request.