Glucocorticoids and Osteoporosis

There have been numerous studies outlining the problem of corticosteroid use in asthma treatment. 

Goldstein, et al. studied chronic glucocorticoid therapy-induced osteoporosis in patients with obstructive lung disease. 

They report long-term glucocorticoid (GC) therapy has been instrumental in decreasing morbidity and mortality in a variety of chronic inflammatory diseases, including persistent asthma. 

One of the important and often unrecognized side effects of chronic GC therapy is secondary osteoporosis. The risk of GC-induced bone loss is roughly correlated with daily dose, duration, and total cumulative lifetime dose of GC treatment. 

Oral prednisone increases the risk of bone loss and fracture. High doses of inhaled GCs may also increase the risk of osteopenia/osteoporosis, but the risk appears to be less than that associated with oral GCs. 

Hormone replacement therapy, oral and parenteral bisphosphonates, supplemental calcium and vitamin D, calcitonin, and fluoride compounds have been used, experimentally, in the management of GC-induced bone loss. 

Asthma and COPD specialists are key prescribers of oral and inhaled steroids and are likely to encounter patients with significant bone loss. 

Despite known risk factors and the availability of reliable diagnostic tools to recognize bone loss, the opportunity to slow, reverse, and treat bone loss is often missed.¹⁶¹

As noted elsewhere, magnesium deficiency is common in asthmatics. 

Magnesium promotes the absorption and metabolism of calcium. As a result, magnesium deficiency may lead to impairment of bone formation and may be a contributing factor to asthma-related osteoporosis of long-term corticosteroid users.

Corticosteroid medications increase the kidney’s loss of calcium and decrease intestinal absorption of calcium. 

Early intervention is critical since most of the bone loss caused by corticosteroids happens at the start of corticosteroid treatment.

Iatrogenic osteoporosis is a very common secondary osteoporosis found in patients treated with large dosages of glucocorticosteroids of lengthy duration.  

2 cases of bronchial asthma, 2 cases of rheumatoid arthritis, 1 case of skin disease and 1 case of callagenosis were examined for bone mineral density at the Tianjin Medical University. 

5 of the 6 cases were treated with prednisone of 5-30 mg daily, while the 6^th case received Dexamethasone (.75g daily). The average treatment time was 1.56 years. 

After one year of supplementation with hormones, calcium and vitamin D, the mineral contents in the bones of all 6 patients were increased and the biochemisty indexes improved.¹⁴³

In another controlled and randomized trial, the effects of treatment with vitamin D (1,000 IU daily), calcium (1,000 g daily), and ethan-1-hydroxy-1,1-diphosphonate (EHDP; 7.5 mg/kg body weight) were examined on vertebral bone mass in fourteen asthmatics undergoing long-term treatment with systemically applied corticosteroids. 

Results of the measurements before treatment and after six months were compared with those of an untreated control group of nineteen asthmatics. 

Bone density increased during the observation period by 5% in the treated group, compared with a decrease of 4.3% in the untreated control group. 

Moreover, in the treated group no radiologically visible new fractures occurred; in the control group new fractures were observed in 21% of the patients.¹⁴⁴

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Corticosteroids and Loss of Bone Density

A study reported in the Annals of Allergy & Asthma Immunology, January, 2005 calls for strategies to “reduce the systemic effects of inhaled corticosteroids.” These effects refer to the fact that “Inhaled corticosteroids are absorbed into the systemic circulation and therefore have the potential to cause adverse effects on bone. Several of the larger studies showed that inhaled corticosteroids cause a dose-related reduction in bone mineral density. Three cross-sectional studies found a dose-related increase in fractures in people taking an inhaled corticosteroid compared with controls. Prospective studies found a short-term reduction in growth velocity in children taking an inhaled corticosteroid, although target adult height is usually achieved.

The researchers concluded that, “Since osteoporotic fracture is common in elderly patients and up to 5% of the population in more developed countries take an inhaled corticosteroid, these findings have public health implications.”²²⁹

Thus, the use of calcium, magnesium and vitamin D supplements to offset bone loss from asthma drugs appears warranted.

NIH Recommendations for Calcium

The National Institutes of Health recommend that women who are premenopausal get 800 mg of elemental calcium per day and women who are postmenopausal get 1500 mg of elemental calcium per day. 

Some researchers recommend that all persons on corticosteroid therapy get 1500 mg of calcium per day either through their diet or by supplements. 

Unfortunately, to get 1500 mg of calcium a day from your diet, you would have to consume one selection from each column, every day:

It would appear the only reasonable way of achieving 1500 mg of calcium each and every day is through nutritional supplementation.

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