Antiresorptive therapy in asthmatic patients receiving high-dose inhaled steroids: a prospective study for 18 months

The effects of corticosteroids on bone growth and bone density

OBJECTIVE

To define the effects of both parenteral and inhaled corticosteroids on bone growth in children and the development of osteopenia and osteoporosis in children and adults.

DATA RESOURCES

Articles in PubMed and MEDLINE published from 1983 to 2008 were searched. Keywords used included corticosteroids and bone growth, osteopenia, osteoporosis, and bisphosphonates.

STUDY SELECTION

Publications reviewed include randomized, placebo-controlled studies of both children and adults.

RESULTS

Because systemic and high-dose inhaled corticosteroids affect bone growth of children taking these medications, stadiometry should be used to measure the growth of children. Osteoporosis due to repetitive courses of oral or parenteral corticosteroids and inhaled corticosteroids can develop gradually in the aging adult. Prophylaxis against osteoporosis requires an index of suspicion, assessment of bone density, supplemental calcium and vitamin D, and use of bisphosphonates to prevent bone fractures that could compromise the patient's quality of life.

CONCLUSION

Preventing corticosteroid-induced effects on bone metabolism can allow effective treatment of allergic disease without long-term adverse effects.

Recognizing and treating glucocorticoid-induced osteoporosis in patients with pulmonary diseases

Glucocorticoids are frequently used to treat patients with pulmonary diseases, but continuous long-term use of glucocorticoids may lead to significant bone loss and an increased risk of fragility fractures. Patients with certain lung diseases, regardless of pharmacotherapy-particularly COPD and cystic fibrosis-and patients waiting for lung transplantation are also at increased risk of osteoporosis. Fragility fractures, especially of the hip, will have substantial effects on the health and well-being of older patients. Vertebral collapse and kyphosis secondary to glucocorticoid-induced osteoporosis (GIO) may affect lung function. Identification of patients with osteopenia, osteoporosis, or fragility fractures related to osteoporosis is strongly recommended and should lead to appropriate treatment. Prevention of GIO in patients receiving continuous oral glucocorticoids is also recommended. In patients receiving either high-dose inhaled glucocorticoids or low- to medium-dose inhaled glucocorticoids with frequent courses of oral glucocorticoids, bone mineral density measurements should be performed to screen for osteopenia and osteoporosis. A bisphosphonate (risedronate or alendronate), calcium and vitamin D supplementation, and lifestyle modifications are recommended for the prevention and treatment of GIO.

Systematic review of the evidence regarding potential complications of inhaled corticosteroid use in asthma: collaboration of American College of Chest Physicians, American Academy of Allergy, Asthma, and Immunology, and American College of Allergy, Asthma, and Immunology

INTRODUCTION

The available clinical guidelines have been successful in improving awareness of the inflammatory nature of asthma and have promoted the use of inhaled corticosteroids (ICSs) to achieve long-term control of symptoms. Because of lingering concerns over the possible adverse consequences of ICS use, an expert panel was convened with a mandate to identify the critical questions that impact decisions regarding the use of ICSs and to evaluate the available evidence with respect to risk.

METHODS

A university librarian retrieved citations and abstracts from the MEDLINE and EMBASE databases using a list of National Library of Medicine search terms and key words. Reviewers were asked to systematically abstract relevant information from each of their assigned articles and to list their own clinical or scientific conclusions based on the study results. A predefined grading algorithm was used to calculate a summary quality rating score for the relevant evidence.

RESULTS

The results are presented as a series of key questions followed by a summary of the relevant evidence. An evidence grade is assigned, followed by a summary statement reflecting the panel's consensus opinion following review.

CONCLUSIONS

The preponderance of evidence supports a conclusion that the proven clinical effectiveness of ICS treatment decidedly outweighs the proven risks.

Cortisol and the renal handling of electrolytes: role in glucocorticoid-induced hypertension and bone disease

Hypertension and osteoporosis are characteristic clinical features in patients with Cushing's syndrome or in those on glucocorticoid (GC) treatment. These two distinct complications of GC excess share one common denominator: an abnormal handling of cations, sodium (Na(+)) and calcium (Ca(2+)), either primarily or in part by the kidney tubule. The principal mechanism of GC-induced hypertension is overstimulation of the non-selective mineralocorticoid receptor (MR), resulting in renal Na(+) retention, volume expansion and finally to an increase in blood pressure. In mineralocorticoid target organs, such as the kidney, the MR is protected from GC occupation by the enzyme 11beta-hydroxysteroid dehydrogenase type 2 (11betaHSD2), a gate-keeping enzyme, which converts cortisol to receptor-inactive cortisone. This enzyme allows aldosterone to be the physiological agonist of the MR despite significantly higher circulating levels of cortisol. Kinetic properties of 11betaHSD2 suggest that saturability of this enzyme can already be achieved at high-normal physiological plasma cortisol levels, thereby leading to ovestimualtion of the MR by cortisol in states of GC excess. The mechanisms of GC action on bone turnover are more complex. GCs increase bone resorption, inhibit bone formation and have an indirect action on bone by decreasing intestinal Ca(2+) absorption, but also inducing a sustained renal Ca(2+) excretion. The latter appears to be mediated through stimulation of the MR by GC. The prevention and treatment of GC-induced hypertension and osteoporosis include the use of the minimal effective dose of GC, some general measures, and the use of some specific drugs. Modulation of renal Na(+) and Ca(2+) excretion with some, but not all, diuretics represents an important specific (for hypertension) or supportive (for bone disease) therapeutic intervention.

COPD and osteoporosis

Osteoporosis, with resulting fractures, is a significant problem in patients with advanced COPD. The etiology for the bone loss is diverse but includes smoking, vitamin D deficiency, low body mass index, hypogonadism, sedentary lifestyle, and use of glucocorticoids. Effective strategies to prevent bone loss and/or to treat osteoporosis include calcium and vitamin D, hormone replacement when indicated, calcitonin, and bisphosphonate administration. However, many patients remain undiagnosed until their first fracture because of the lack of recognition of the disease. With an increased awareness by pulmonologists and the increased use of preventive strategies, the impact of osteoporosis on those patients with COPD should decrease.

Effect of an inhaled glucocorticoid, flunisolide, on bone mineral density: a 2-year prospective, controlled trial

OBJECTIVE

To determine the long-term effect of an inhaled glucocorticoid, flunisolide, on bone mineral density in a prospective, controlled study.

METHODS

Patients with asthma treated with inhaled glucocorticoids, but not requiring other types of glucocorticoid treatment, were recruited as study patients (N = 11). All study patients were treated with inhaled flunisolide, 500 mg twice a day for a 2-year period, for consistency. Patients with asthma not requiring any type of glucocorticoid treatment were recruited as control subjects (N = 18). All patients were between the ages of 30 and 50 years, and all female patients were premenopausal. Measurements of bone mineral density, serum bone-specific alkaline phosphatase, serum osteocalcin, 24-hour urine hydroxyproline-to-creatinine ratio, forced expiratory volume in 1 second/forced vital capacity, and forced expiratory flow, midexpiratory phase were obtained at baseline and repeated in 1 year and again in 2 years.

RESULTS

No statistically significant changes were noted in bone mineral density measured at the lumbar spine, femoral neck, Ward's triangle, or femoral trochanter in the users of inhaled flunisolide in comparison with the control subjects at 1 year or at 2 years, with one exception. The percentage change from baseline of bone mineral density measured at the femoral trochanter at 1 year was greater in the inhaled flunisolide users than in the control group, 3.1% versus -0.8%, respectively (P = 0.01). No statistically significant changes were found in markers of bone turnover or measures of asthma severity.

CONCLUSION

Inhaled flunisolide, administered in standard doses, had no deleterious effect on bone mineral density or on biochemical markers of bone turnover after a 2-year period.

Chronic glucocorticoid therapy-induced osteoporosis in patients with obstructive lung disease

Long-term glucocorticoid (GC) therapy has been instrumental in decreasing morbidity and mortality in a variety of chronic inflammatory diseases, including persistent asthma. Long-term GC therapy is also widely prescribed for COPD. One of the important and often unrecognized side effects of chronic GC therapy is secondary osteoporosis. The risk of GC-induced bone loss is roughly correlated with daily dose, duration, and total cumulative lifetime dose of GC treatment. Oral prednisone increases the risk of bone loss and fracture. High doses of inhaled GCs may also increase the risk of osteopenia/osteoporosis, but the risk appears to be less than that associated with oral GCs. Hormone replacement therapy, oral and parenteral bisphosphonates, supplemental calcium and vitamin D, calcitonin, and fluoride compounds have been used, experimentally, in the management of GC-induced bone loss. Asthma and COPD specialists are key prescribers of oral and inhaled steroids and are likely to encounter patients with significant bone loss. Despite known risk factors and the availability of reliable diagnostic tools to recognize bone loss, the opportunity to slow, reverse, and treat bone loss is often missed. We present a review of the current literature regarding the incidence, treatment, and prevention of osteopenia/osteoporosis secondary to chronic GC therapy in adult asthma and COPD patients. Guidelines are presented regarding the identification of patients at risk for developing GC-induced secondary bone loss, and therapeutic alternatives are discussed.

Atopic diseases and upper respiratory infections

This article reviews information on the topics of asthma, allergic rhinitis, atopic dermatitis, food allergy, and upper respiratory infections. The asthma section includes a review of inhaled steroids and their potential side effects. New findings on the pathogenesis, triggers, and therapies of atopic dermatitis and new insights into food hypersensitivity reactions are presented. Recent publications in the areas of allergic rhinoconjunctivitis and upper respiratory infections are also reviewed.