New research on chronic corticosteroid use

Nov 10 2008

An analysis of large population databases has recently yielded important findings about chronic corticosteroid use.

According to experts at the annual meeting of the American College of Allergy, Asthma and Immunology (ACAAI) in Seattle, there is some unexpected impact on bones.

"For many diseases corticosteroids have been 'miracle drugs,' effectively controlling symptoms where no other medications had succeeded before," said Rebecca Green, M.D., Ph.D., assistant professor, pediatric endocrinology and diabetes, Washington University School of Medicine in St. Louis, Mo. "However, along with the benefits of high dose corticosteroids, important side effects have emerged."

Inhaled corticosteroids are one of the most effective medications for controlling asthma. These anti-inflammatory medications reduce swelling in the airways, improve lung function and act to prevent asthma episodes or "asthma attacks." Intervention with inhaled corticosteroids can improve asthma control and reduce emergency department visits, hospitalization and deaths.

The side effects attributed to corticosteroids include decreased bone mineral density and reduced bone mass, and also in children, reduced growth rate. According to Dr. Green, strategies to alleviate these effects include minimizing oral doses and adding topical or inhaled steroids to provide the same anti-inflammatory benefit in the areas affected by inflammation while avoiding systemic effects. Disturbance in bone acquisition in childhood can reduce peak bone mass and therefore significantly impact the life time risk of osteoporosis.

"One of the challenges has been distinguishing the effects of the inflammatory process itself on bone mass and growth, and the effects of corticosteroids on bone growth from the effects of corticosteroids on bone mass," she said.

"Analysis of large population databases has recently yielded extremely valuable data about corticosteroids and fractures, with some unexpected impact of lower doses. Analysis of the same database for inhaled steroid use in adults showed a small increase in fracture risk in users of inhaled steroids compared to control, but comparable risk of fracture in inhaled steroid users compared to individuals using inhaled bronchodilators. This suggests that the increased risk of fracture was secondary to the disease itself, not the inhaled steroids," Dr. Green explained.

The Childhood Asthma Management Program (CAMP) study showed that inhaled corticosteroids are safe and effective for the long-term treatment of children with mild to moderate asthma. CAMP was a landmark study funded by the National Heart, Lung, and Blood Instititute (NHLBI) of the National Institutes of Health, which began in 1993 and continued in its follow-up phases through 2007.

A follow-up CAMP cohort study conducted by H. William Kelly, PharmD, and colleagues, assessed the effects of multiple short courses or oral steroids and long-term inhaled corticosteroids on bone mineral growth over a period of years.

"There was a significant dose-dependent decrease in bone mineral accretion from oral corticosteroid bursts in boys, but not girls," said Dr. Kelly, professor emeritus of pediatrics, University of New Mexico Health Sciences Center, Albuquerque, N.M. "Inhaled corticosteroid use has the potential for reducing bone mineral growth in male children progressing through puberty, but this risk is likely to be outweighed by the ability to reduce the amount of oral corticosteroids used in these children," he said.

The study found that neither oral corticosteroid bursts or inhaled corticosteroids were significantly related to 27 fractures in females and 40 in males.

The appropriate use of corticosteroids is recommended in the current "Guidelines for the Diagnosis and Management of Asthma," the Expert Panel #3 report of the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung and Blood Institute. Inhaled corticosteroids are known to have far fewer side effects than the long-term use of oral formulations of these drugs.

Patient information on allergic diseases including the brochure titled Take Control: A Guide for People with Asthma is available by calling the ACAAI toll free number at (800) 842-7777 or visiting its Web site at www.acaai.org.