Could Your Asthma Inhaler Cause Osteoporosis?

Date: 18 February, 2005
Tell your children and grandchildren: Think before you puff.

You probably think I’m talking about smoking, right? Well, I certainly would take any opportunity to get people off of cigarettes. I smoked for enough years to know first-hand the horrible things it can do.

But in this case, I’m talking about something else. I just recently learned that puffing or inhaling steroids, like those found in asthma inhalers, may pose a substantial risk to women’s bone health.

A new Harvard study in the US, published in ‘The New England Journal of Medicine,’ showed that the regular use of inhaled steroids causes bone loss at the hip in women between the ages of 18 and 45. The more ‘puffs’ taken each day, the greater the rate of bone loss.

Inhaled steroids are by far the most common treatment for asthma.

This finding could affect millions

Doctors have known for some time that taking steroids in pill form contributes to bone loss in both men and women. But research on the effects of inhalers had been less clear-cut. In reviewing research on the issue, the Harvard team found the data was often unreliable: inhaler dosages weren’t verified, the duration of the study was too short, the sample was too small, etc. So they set out to do a comprehensive study that addressed all the possible variables that could skew the results.

Over five years, Harvard recruited 109 pre-menopausal women with asthma. The participants were divided into three groups: those not taking inhaled steroids, those taking four to eight puffs per day, and those taking more than eight puffs per day. All the women were between 18 and 45, and none of them smoked, took drugs that effect bone metabolism, or had recently taken oral or injected steroids. All the participants also underwent a comprehensive series of blood and urine tests, along with baseline bone density screenings, to rule out any existing bone loss at baseline.

The two groups who used an inhaler were all provided with a supply of triamcinolone acetonide, a type of glucocorticoid representative of the inhaled steroids on the market. The women kept track of their usage in diaries, and the usage was verified by a monitoring device. The research team analysed each woman’s nutritional history and provided calcium and vitamin D supplements for those who fell below the recommended daily allowance for these bone-building nutrients.

After accounting for just about every confounding factor, the researchers found undeniable evidence that the inhaled steroids contributed to bone loss in the women tested. And while the study specifically focused on premenopausal women, it noted that continued inhaler use after menopause could contribute to even more bone loss and risk of fracture over time for older women with asthma.

‘A woman with asthma who was treated with the equivalent of 1200 micrograms of inhaled glucocorticoids (six puffs of triamcinolone acetonide twice daily) beginning at 30 years of age, and who entered menopause at 50 years of age, would have a predicted bone mass at the [hip] that was 0.106 g per square centimetre less than that of an untreated woman of similar age.’ That may not seem like a lot – but realise that small measurement translates into a 50-year-old woman having more than TWICE the risk of hip fracture than that of a healthy 65-year-old woman. In effect, it could age your bones 15 years – and double your risk of injury.

This study didn’t address the risks for men who use inhaled steroids. But considering that oral steroids are known to damage men’s bone metabolism as well, there’s reason to wonder. I’ll keep looking for more information about how this common asthma treatment might affect men.

Meanwhile, the Harvard team listed some recommendations to help minimise the damage of inhaled steroids on women: use the lowest effective dosage in inhalers, engage in weight-bearing exercise, and supplement with calcium and vitamin D.
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