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More Windex: Steroid Inhalers and Bone Health

steroid inhalers and fractures 2

Steroid inhalers are common these days. The idea was supposed to
be that by inhaling low doses of steroids, we could avoid the side
effects of higher oral and intravenous steroids. Did this turn out
to be true? Nope. Let’s dig in.

Steroids are Super Nasty

As I wrote yesterday, steroids are the Windex of medicine. Do
you remember the father in My Big Fat Greek Wedding who would spray
Windex on everything? Well, that’s how most physicians view
steroids. We use them for everything from knee pain to asthma.

The problem? Steroids have been associated with all sorts of
nasty side effects. For example, a bone disease where your bones
turn to mush (osteonecrosis). This happens in a dose-dependent
fashion (6). Meaning the more steroids you get exposed to, the more
likely you are to get this awful disease.

Here are some other issues:

  • Elevated blood sugar
  • Increased risk of infection
  • Glaucoma
  • Suppression of adrenal gland hormone production
  • Fluid retention
  • Confusion or delirium
  • High blood pressure
  • Weight gain and cushingoid syndrome (bizarre fatty deposits
    like a moon face)
  • Osteoporosis

Steroid Inhalers

334 million people worldwide are diagnosed with asthma, a
condition characterized by airway constriction that makes it hard
to breathe. Steroids can reduce inflammation which can open the
airways. Hence, they have become a mainstay of asthma
treatment.

When steroid inhalers made their debut a few decades ago, the
idea was simple. Reduce the dose of steroids and make it easy for
the patient to conveniently inhale every day with a small device
that they can carry. This will reduce the need for higher dose
steroids that we know can cause severe side effects and patients
will be safer. However, research now shows that this was wishful
thinking.

New Research

By examining data from anonymized health records, researchers
who authored an October 2020 study published in the journal Thorax
concluded that patients on steroids for asthma had higher rates of
osteoporosis and fractures than those who didn’t use steroids.
And the higher the cumulative dose and the longer they were on the
medication, the greater the risk.

Individuals who were given 9 or more prescriptions for steroid
pills in a year were at the greatest risk of osteoporosis — more
than 4 times more likely to develop the degenerative bone disease.
They were also at higher risk for fragility fractures, even after
accounting for influencing factors like smoking, weight, and
alcohol intake. The most surprising thing in the study was that the
risk for fractures and osteoporosis was elevated by about 60% for
steroid inhalers. That’s not supposed to happen.

What We Know

Several previous studies — including one from September 2010,
have linked corticosteroid use and osteonecrosis, a degenerative
disease that results from fewer stem cells and the eventual
collapse of the bone (2). Even short-term use has been associated
with an increased risk of fractures, blood clots and sepsis,
according to an April 2017 study in BMJ (3).

But there’s also some potentially promising evidence that
vitamin E supplementation may prevent steroid-induced
osteonecrosis, according to a February 2010 study (4). And an
August 2014 study suggests that curcumin’s anti-inflammatory
properties may help alleviate some asthma symptoms when used in
conjunction with corticosteroids (5). This could lessen the number
of inhaler prescriptions required.

The upshot? Patients who use steroid inhalers are at risk for
bone diseases. That’s a fact that would likely surprise most
physicians who write these scripts. So like everything else in
healthcare, buyer beware!

______________________________________________

Related

>>
Can Supplements Help with Asthma?

References

1. Chalitsios CV, 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. 2020 Oct 21:thoraxjnl-2020-215664. doi:
10.1136/thoraxjnl-2020-215664. Epub ahead of print. PMID:
33087546.

2. Powell C, Chang C, Naguwa SM, Cheema G, Gershwin ME. Steroid
induced osteonecrosis: An analysis of steroid dosing risk.
Autoimmun Rev. 2010 Sep;9(11):721-43. doi:
10.1016/j.autrev.2010.06.007. Epub 2010 Jul 9. PMID: 20621176.

3. Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM,
Ayanian JZ, Nallamothu BK. Short term use of oral corticosteroids
and related harms among adults in the United States: population
based cohort study. BMJ. 2017 Apr 12;357:j1415. doi:
10.1136/bmj.j1415. PMID: 28404617.

4. Kuribayashi M, Fujioka M, Takahashi KA, Arai Y, Ishida M,
Goto T, Kubo T. Vitamin E prevents steroid-induced osteonecrosis in
rabbits. Acta Orthop. 2010 Feb;81(1):154-60. doi:
10.3109/17453671003587101. Erratum in: Acta Orthop. 2010 Oct;
81(5):647. PMID: 20146637.

5. Abidi A, Gupta S, Agarwal M, Bhalla HL, Saluja M. Evaluation
of Efficacy of Curcumin as an Add-on therapy in Patients of
Bronchial Asthma. J Clin Diagn Res. 2014 Aug;8(8):HC19-24. doi:
10.7860/JCDR/2014/9273.4705. Epub 2014 Aug 20. PMID: 25302215.

(6) Yao TC, Huang YW, Chang SM, Tsai SY, Wu AC, Tsai HJ.
Association Between Oral Corticosteroid Bursts and Severe Adverse
Events: A Nationwide Population-Based Cohort Study [published
online ahead of print, 2020 Jul 7]. Ann Intern Med.
2020;10.7326/M20-0432. doi:10.7326/M20-0432

steroid inhalers and fractures 2

Steroid inhalers are common these days. The idea was supposed to
be that by inhaling low doses of steroids, we could avoid the side
effects of higher oral and intravenous steroids. Did this turn out
to be true? Nope. Let’s dig in.

Steroids are Super Nasty

As I wrote yesterday, steroids are the Windex of medicine. Do
you remember the father in My Big Fat Greek Wedding who would spray
Windex on everything? Well, that’s how most physicians view
steroids. We use them for everything from knee pain to asthma.

The problem? Steroids have been associated with all sorts of
nasty side effects. For example, a bone disease where your bones
turn to mush (osteonecrosis). This happens in a dose-dependent
fashion (6). Meaning the more steroids you get exposed to, the more
likely you are to get this awful disease.

Here are some other issues:

  • Elevated blood sugar
  • Increased risk of infection
  • Glaucoma
  • Suppression of adrenal gland hormone production
  • Fluid retention
  • Confusion or delirium
  • High blood pressure
  • Weight gain and cushingoid syndrome (bizarre fatty deposits
    like a moon face)
  • Osteoporosis

Steroid Inhalers

334 million people worldwide are diagnosed with asthma, a
condition characterized by airway constriction that makes it hard
to breathe. Steroids can reduce inflammation which can open the
airways. Hence, they have become a mainstay of asthma
treatment.

When steroid inhalers made their debut a few decades ago, the
idea was simple. Reduce the dose of steroids and make it easy for
the patient to conveniently inhale every day with a small device
that they can carry. This will reduce the need for higher dose
steroids that we know can cause severe side effects and patients
will be safer. However, research now shows that this was wishful
thinking.

New Research

By examining data from anonymized health records, researchers
who authored an October 2020 study published in the journal Thorax
concluded that patients on steroids for asthma had higher rates of
osteoporosis and fractures than those who didn’t use steroids.
And the higher the cumulative dose and the longer they were on the
medication, the greater the risk.

Individuals who were given 9 or more prescriptions for steroid
pills in a year were at the greatest risk of osteoporosis — more
than 4 times more likely to develop the degenerative bone disease.
They were also at higher risk for fragility fractures, even after
accounting for influencing factors like smoking, weight, and
alcohol intake. The most surprising thing in the study was that the
risk for fractures and osteoporosis was elevated by about 60% for
steroid inhalers. That’s not supposed to happen.

What We Know

Several previous studies — including one from September 2010,
have linked corticosteroid use and osteonecrosis, a degenerative
disease that results from fewer stem cells and the eventual
collapse of the bone (2). Even short-term use has been associated
with an increased risk of fractures, blood clots and sepsis,
according to an April 2017 study in BMJ (3).

But there’s also some potentially promising evidence that
vitamin E supplementation may prevent steroid-induced
osteonecrosis, according to a February 2010 study (4). And an
August 2014 study suggests that curcumin’s anti-inflammatory
properties may help alleviate some asthma symptoms when used in
conjunction with corticosteroids (5). This could lessen the number
of inhaler prescriptions required.

The upshot? Patients who use steroid inhalers are at risk for
bone diseases. That’s a fact that would likely surprise most
physicians who write these scripts. So like everything else in
healthcare, buyer beware!

______________________________________________

Related

>>
Can Supplements Help with Asthma?

References

1. Chalitsios CV, 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. 2020 Oct 21:thoraxjnl-2020-215664. doi:
10.1136/thoraxjnl-2020-215664. Epub ahead of print. PMID:
33087546.

2. Powell C, Chang C, Naguwa SM, Cheema G, Gershwin ME. Steroid
induced osteonecrosis: An analysis of steroid dosing risk.
Autoimmun Rev. 2010 Sep;9(11):721-43. doi:
10.1016/j.autrev.2010.06.007. Epub 2010 Jul 9. PMID: 20621176.

3. Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM,
Ayanian JZ, Nallamothu BK. Short term use of oral corticosteroids
and related harms among adults in the United States: population
based cohort study. BMJ. 2017 Apr 12;357:j1415. doi:
10.1136/bmj.j1415. PMID: 28404617.

4. Kuribayashi M, Fujioka M, Takahashi KA, Arai Y, Ishida M,
Goto T, Kubo T. Vitamin E prevents steroid-induced osteonecrosis in
rabbits. Acta Orthop. 2010 Feb;81(1):154-60. doi:
10.3109/17453671003587101. Erratum in: Acta Orthop. 2010 Oct;
81(5):647. PMID: 20146637.

5. Abidi A, Gupta S, Agarwal M, Bhalla HL, Saluja M. Evaluation
of Efficacy of Curcumin as an Add-on therapy in Patients of
Bronchial Asthma. J Clin Diagn Res. 2014 Aug;8(8):HC19-24. doi:
10.7860/JCDR/2014/9273.4705. Epub 2014 Aug 20. PMID: 25302215.

(6) Yao TC, Huang YW, Chang SM, Tsai SY, Wu AC, Tsai HJ.
Association Between Oral Corticosteroid Bursts and Severe Adverse
Events: A Nationwide Population-Based Cohort Study [published
online ahead of print, 2020 Jul 7]. Ann Intern Med.
2020;10.7326/M20-0432. doi:10.7326/M20-0432

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