April 21, 2000 -- A steroid inhaler may be your best friend if you have asthma. It's easy to use and generally has fewer side effects than steroid pills. But a new study shows that high doses of inhaled steroids for asthma may in fact lead to weak and thinning bones -- a side effect that, until now, was primarily associated with steroid pills.
The study also suggests that the more asthma patients used inhaled steroids, the weaker their bones became.
Inhaled steroids are frequently used to decrease inflammation and airway blockage and are one of the main treatments used for asthma. Doctors and patients generally prefer them to steroid pills because steroid pills have more side effects -- one of the most troubling being bone loss that can lead to osteoporosis.
However, physicians and researchers were not sure if enough inhaled steroids got into the bloodstream to cause bone loss. So this study looked at people who had been on inhaled steroids for asthma for about six years and tested their bone density, a sign of bone strength.
This study points out that another risk of using inhaled steroids for asthma may indeed be bone loss, according to Norman H. Edelman, MD, who was not involved in the study. He says that doctors and patients have to weigh the risks of asthma against osteoporosis when making a decision about treatment with inhaled steroids. Edelman is the dean of the School of Medicine at the State University of New York at Stony Brook and a scientific consultant to the American Lung Association.
The researchers found that the patients with asthma taking high doses of inhaled steroids had a significant loss in bone density. The three inhaled steroids used in the study were Beclovent, Flovent, and Pulmicort. Other steroid inhalers used in the U.S. that were not included in the study are Aerobid and Azmacort. These results are published in the April 22 issue of the medical journal The Lancet.
You should tell your doctor about this new study, Edelman says. "Ask your physician what you can do to protect your bones. Also ask what they are doing to ensure that your risk of bone density loss is as low as possible."
"The key question is, how do you get the benefit of inhaled steroids with the least amount of risk?" says Thomas Plaut, MD, who reviewed the study for WebMD. "Not everybody needs them. Someone who does a good job of cleaning up their environment and eliminating allergens such as dust, pollen, and animal dander can cut their need for inhaled steroids by up to 50%."
He says people with mild asthma -- about 60% of all asthma patients -- can often get relief by using instead a medication that doesn't contain steroids to relieve inflammation, such as Accolate, Singulair, or Tilade. However, for many patients, particularly those with moderate or severe asthma, that will not be sufficient. Plaut is the author of Dr. Tom Plaut's Asthma Guide. He is in private practice in Amherst, Mass., and acts as a consultant on asthma issues to health plans and state and municipal health departments.
"Our study suggests that ... patients should therefore take the lowest dose that adequately controls their asthma," the authors write.
Plaut also strongly recommends the use of a spacer, which is a device that attaches to the inhaler. A spacer catches the large particles of steroids and lets you breathe in only the small particles. The large particles are what lead to most of the side effects, but do not add any benefit, Plaut says. "Be sure to rinse your mouth and spit out so you don't swallow any of the medication. Inhaled steroids in the mouth promote yeast infections there and also disperse steroids throughout the body."
Patients with asthma should be aware that they are at increased risk for osteoporosis and therefore take the steps that are generally advised to build and maintain strong bones. Plaut advises all his female asthma patients to take 1,500 milligrams of calcium and 400 units of vitamin D every day. Edelman notes that the need to build and maintain strong bones is yet another reason, in addition to its heart and muscle benefits, to recommend exercise for asthma patients.
"However, since exercise itself can sometimes cause airway narrowing, patients with asthma should engage in the right kind of exercise: walking rather than sprinting. You don't want intensely aerobic games like soccer. Swimming is particularly beneficial for asthmatics, because it takes place in a humid environment, so the airways don't dry out."
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- Researchers report patients who took high doses of inhaled steroids for their asthma may be weakening and thinning their bones.
- Observers note the study demonstrates that loss of bone density is a risk that needs to be weighed before patients start using inhaled steroids to control asthma. Patients also should be talking with their doctors about protecting their bones.
- The authors stress that patients should take the lowest dose that controls their asthma. Another doctor urges patients to use a spacer, which attaches to an inhaler and catches the large steroid particles so only the smaller ones are inhaled. Large particles don't add benefit to therapy and tend to cause side effects.