If you use one type of inhaled steroid long-term as a therapy for chronic obstructive pulmonary disease (COPD), you face a higher risk of developing a loss of bone mineral density, finds a new study from the Mayo Clinic.1
Disease Risk Factors
COPD is an umbrella term that doctors and other medical experts use to describe a group of lung diseases that includes chronic bronchitis and emphysema. It is the fourth leading cause of death in the United States. Cigarette smoking is, by far, the biggest risk factor for the disease, but inhaling certain dusts and chemicals on the job is another potential cause. Symptoms of COPD include chronic cough, sputum production and shortness of breath.2
Pulmonary hypertension (PH) is a common complication of COPD. The latter disease can potentially lead to PH, which is characterized by constriction of the pulmonary artery, the blood vessel that runs between the heart and lungs.3
An 'Off Label' Therapy
Inhaled corticosteroids are currently not approved as a medication for COPD;4 however, some physicians prescribe them "off-label" as a therapy to help reduce the inflammation in the lungs that often accompanies the illness. Some of the more commonly prescribed inhaled corticosteroids include triamcinolone, belcomethasone, flunisolide, and fluticasone.
In this study, John Connett, MD, and his colleagues tested the efficacy of triamcinolone, an inhaled glucocorticosteroid (an anti-inflammatory compound that belongs to the larger family of corticosteroids) for COPD. The drug was given twice each day to one group of patients, and a second group was given a placebo, as a comparison. In all, 412 people who were current smokers or recent quitters with mild to moderate COPD took part.
Connett's team followed each patient for a total of 3 years.
Drug Linked to Bone Loss
At the end of the study period, patients taking triamcinolone showed a nearly 2% decrease in bone mineral density, on average, at the hip, and a reduction of 0.35% at the spine compared to the other patients. Those taking placebo had increases in bone mineral density on the spine of about 1%. The differences were found to be significant, Connett and his colleagues reported.
While these losses aren't considered serious for people who don’t already have thinning bones, Connett's group warns that the reductions in bone mineral density of this magnitude could be risky for people who have weakening bones. If inhaled glucocorticosteroids are used even longer, the risks could be even higher, they said.
The findings suggest that inhaled corticosteroids should be prescribed with caution for COPD, Connett says, adding that doctors should seriously consider performing a bone density test beforehand.
Triamcinolone is used less widely now than other inhaled corticosteroids like budesonide and fluticasone. Thus, the effect on bone mineral density of these newer drugs isn't known, he said.
Bone Fracture Risk Found
This isn't the first study that linked inhaled corticosteroids to the risk of weakened bones. Last year, doctors published a study suggesting the drugs increase the risk of certain bone fractures.5
Comparing data of patients treated at an area hospital for COPD with information on patients without the disease, Todd Lee, PharmD, PhD, at Hines VA Hospital in Maywood, Illinois, and Kevin Weiss, MD, in the department of Medicine at the University of Illinois found that those who had been prescribed corticosteroids had a high incidence of bone fractures compared to those who had not been given the medications. The two compared corticosteroid prescriptions with the prevalence of bone fractures among the patients studied.
The doctors noted that patients at highest risk were those who received at least 700 micrograms of corticosteroids per day. (Patients in the Mayo Clinic study were given two daily doses of 600 micrograms each.)
As a result, the investigators urged physicians to consider prescribing the lowest effect dose of inhaled corticosteroids for these patients.
1. Scanlon PD, Connett JE, Wise RA et al. Loss of bone density with inhaled triamcinolone in Lung Health Study II. Am J Respir Crit Care Med 2004 Dec 15;170(12):1302-9. Epub 2004 Sep 16.
2. National Heart, Lung and Blood Institute. National Institutes of Health (NIH). Chronic Obstructive Pulmonary Disease. Available at: http://www.nhlbi.nih.gov/health/public/lung/other/copd_fact.pdf. Accessed February 3, 2005.
3. Naeije R, Barbera JA. Pulmonary hypertension associated with COPD. Crit Care 2001 Dec;5(6):286-9. Epub 2001 Nov 3.
4. Food and Drug Administration.
5. Lee TA, Weiss KB. Fracture risk associated with inhaled corticosteroids use in chronic obstructive pulmonary disease. Am J Resp Crit Care Med 2004 Apr 1;169(7):855-9. [Epub ahead of print: 2004 Jan 7].
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
