Background Asthma and osteoporosis guidelines recommend that patients on high-dose oral steroids (OS) should be considered for bone protection. Patients on low-dose OS, or inhaled corticosteroid (ICS) of any dose, should have their fracture and osteoporosis risk evaluated. The Scottish Intercollegiate Guidelines Network recommend the online risk-calculator QFracture. However, ICS use is not taken into account by any risk-calculator, despite recent evidence that ICS use has systemic effects on bone health.1Patients with a clinically significant 10-year risk of fracture qualify for a Dual-energy X-ray absorptiometry scan (DEXA). No threshold for DEXA referral is identified by the guidelines, though it is suggested to be around 10%. No fracture or osteoporosis screening is undertaken at the tertiary asthma clinic where this project was conducted.
Methods A cross-sectional study was conducted using data from 129 patients between January to March 2021 at a tertiary asthma clinic. The QFracture calculator was used to identify fracture and osteoporosis risk factors. A 10-year risk score was calculated.
Results Over 58% of the cohort had at least two risk factors. 10% of the sample were prescribed frequent OS. 13.2% had a 10-year risk score of 10% or greater. Qfracture risk increases with age, however this association was more marked in the cohort population, even when asthma as a risk factor was taken into account (figure 1). Notably, 50% of the sample were prescribed high-dose ICS. 6 patients had a diagnosis of osteoporosis, of whom only half were prescribed bisphosphonates.
Discussion The fracture risk of patients of this tertiary asthma clinic is underestimated and undertreated. A significant proportion of patients are treated with high-dose ICS; further research is required to evaluate the effect of ICS use on bone health. If this is found to be significant, it should be incorporated in future risk calculators. Until then, a high-suspicion clinical approach for osteoporosis development in patients with severe asthma should be adopted in primary and tertiary care.
Chalitsios C V, Shaw DE, McKeever TM. Risk of osteoporosis and fragility fractures in asthma due to oral and inhaled corticosteroids: two population-based nested case-control studies. Thorax. 2021;76(1):21–8.
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