CHEST Guidelines-Inhaled-Corticosteroids-and-Fractures-in-COPD

Inhaled-Corticosteroids-and-Fractures-in-COPD_ches

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The document examines the relationship between long-term inhaled corticosteroids (ICS) use in patients with Chronic Obstructive Pulmonary Disease (COPD) and the risk of fractures. Although intended for patients with frequent exacerbations or recent hospitalizations, ICS use is still prevalent among 60% of COPD patients who do not meet these criteria. Concerns about this widespread use include the risk of osteoporosis and fractures, especially since COPD patients already have a higher baseline risk of these conditions.<br /><br />Research shows that COPD patients have a 60% increased risk of hip fractures compared to controls, likely due to multiple factors, including inflammation and the use of medications that cause bone demineralization. While long-term oral corticosteroids are known to decrease bone mineral density and increase fracture risk, the effects of ICS have been less clear. Some studies, like the Lung Health Study, found that prolonged ICS use (three years at a high dose) reduced bone mineral density, indicating a potential risk for fractures. However, other studies did not observe the same effects, possibly due to smaller sample sizes and lower statistical power.<br /><br />A large cohort study in Quebec, Canada, found that ICS use increased fracture risk, but mainly after four years of treatment in patients with higher cumulative doses. This aligns with previous findings, suggesting a time and dose-dependent risk of bone demineralization from prolonged ICS use, especially in women predisposed to osteoporosis.<br /><br />The mechanisms by which ICS may contribute to osteoporosis and fracture risk include systemic absorption leading to reduced calcium absorption, increased calcium excretion, and effects on hormone levels that inhibit bone formation.<br /><br />Clinically, the authors suggest minimizing ICS use in COPD patients where possible, using the lowest effective dose, and monitoring bone health in patients requiring long-term therapy to mitigate fracture risk. This approach aims to reduce unnecessary ICS use while addressing significant side effects.

Keywords

inhaled corticosteroids

COPD

fracture risk

osteoporosis

bone mineral density

systemic absorption

calcium absorption

hormone levels

long-term therapy

dose-dependent risk