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Will Asthma Inhalers Weaken Bones?

Asthma inhalers containing steroids calm inflammation in the airways and help with breathing. Do they increase the risk for fractures?

What should you do if a drug you take for one health problem puts you at risk for another condition? We wish this question were purely hypothetical, but all too often a medicine like prednisone (which might be prescribed for a wide range of disorders) could raise the possibility of serious side effects such as cataracts, type 2 diabetes or osteoporosis. Even inhaled corticosteroids, which are prescribed in asthma inhalers and COPD inhalers, may take a toll on bone strength.

Fracture Risk and Inhaled Corticosteroids:

We suspect that a fair number of people believe in the Las Vegas model of medicines. That’s the idea that:

“What happens in Vegas Stays in Vegas.” 

We worry that both health care professionals and patients believe that:

“What’s Sprayed in the Lungs Stays in the Lungs”

In truth, the lungs are a marvelous way to get drugs into the systemic circulation. Just ask anyone who has smoked marijuana!

What About Asthma Inhalers and COPD Inhalers?

An article published in BMC Pulmonary Medicine, Aug. 17, 2023 reviewed 44 randomized controlled trials “to reveal the effect of inhaled corticosteroids on the fracture risk of COPD patients.”

The authors note that:

“Chronic obstructive pulmonary disease (COPD) is a heterogeneous airway disease, characterized by persistent respiratory symptoms and gradual airflow limitation. With high morbidity and mortality, COPD is the third leading cause of death in the world.”

Doctors frequently depend upon inhaled corticosteroids (ICSs) and bronchodilators, referred to as long-acting beta agonists (LABAs), to keep people out of the hospital. Another kind of inhaled medication (long-acting muscarinic receptor antagonsits (LAMAs) are also prescribed for patients with COPD.

Fracture Risk?

The authors of this study write:

“In this systematic review and meta-analysis based on 44 randomized controlled trials (87,594 patients), we found that compared with that without ICSs, inhalation therapy with ICSs was associated with increased risks of fracture.”

People using corticosteroids in combination with other drugs for COPD were 30 to 50 percent more likely to break a bone. The risk from taking budesonide with a metered dose inhaler was especially high, about 75 percent greater than for people not using corticosteroid for their COPD at all. Older patients and those with more severe COPD were at the greatest fracture risk from inhaled corticosteroid use in combination with other medications. The longer patients took inhaled steroids along with LABAs, the greater the risk.

Inhaled Asthma Drugs and Inhaled COPD Drugs Are Life Savers:

Here is the challenge. People with severe breathing problems, whether from COPD or asthma, require effective treatment. Inhalers are considered the mainstay medicines. So there are clear benefits and risks associated with these medications.

That means that the patient and the doctor need to balance the pros and cons of the treatment to determine how to get the most benefit and do the least damage. That is what this reader is concerned about with respect to medications used to keep asthmatic airways open.

Asthma Inhalers and Osteoporosis:

Q. I suffer from asthma and osteoporosis. I am concerned that the asthma medicines that I take (Flovent and Xopenex) have side effects that are affecting my osteoporosis and my essential tremor. Are there any alternatives for my condition?

Choosing Between Strong Bones and Breathing Easy:

A. Flovent contains fluticasone, a cortisone-like drug that has been linked with bone thinning and osteoporosis. Other asthma inhalers that contain corticosteroids (Advair, Pulmicort, QVAR, Symbicort) may also pose a similar risk. This side effect has not been reported with levalbuterol (Xopenex).

Stop Asthma Inhalers Only with Medical Supervision:

That does not mean you can stop using your asthma inhalers, as such drugs represent the foundation of asthma treatment. You’ll need to discuss with your doctor whether changing the dose is an option, and whether that would make a difference in the chance of worsening your osteoporosis and essential tremor.

The same holds true for COPD. People who rely upon inhaled medications, especially corticosteroids and LABAs should be closely monitored for osteopenia or osteoporosis. If such conditions show up, it may be necessary to consider bone-strengthening medications. If this sounds like a pharmaceutical cascade, you are not wrong. Sometimes that is necessary to balance the benefits and risks of essential medicines.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.”.
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  • Peng, S., et al, "Effect of fracture risk in inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis," BMC Pulmonary Medicine, Aug. 17, 2023, DOI: 10.1186/s12890-023-02602-5
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