Do inhaled steroids hurt your bones?

The detrimental effects of oral corticosteroid medications on bones have been known for quite some time, but many of my clients ask me if these issues also apply to inhaled steroid medications, like the ones used to treat asthma and COPD. Will using inhaled corticosteroids increase their risk of fracture?  

What we know about inhaled steroids and bone

It’s been clear for a while that inhaled steroids do affect bone turnover, although so far the effects seem modest:
Children who use inhaled steroids for asthma over long periods of time tend to grow more slowly and have slightly lower bone density and shorter adult height (Sutter & Stein, 2016; Sidoroff et al., 2015), but with no significant increase in fracture risk (Loke et al., 2015).
Studies of older adults with long-standing inhaled corticosteroid use showed modest, but not statistically significant, decreases in bone mineral density (Sarwar et al. 2018) and a similar modest increase in fracture risk (Loke et al. 2011; Seggev, 2012)
A recent study showed abnormal microarchitecture and stiffness in women using inhaled steroids as well as both lower bone density in several parts of the body and architectural weaknesses (Liu et al., 2018).  

What’s more, a 2018 study by Mohn and colleagues showed that use of inhaled corticosteroids suppresses calcium and vitamin D uptake, which in the long term could weaken bone (and I have to wonder whether other key bone-sustaining nutrients that weren’t looked at might also be affected). 

So long story short, long-term use of inhaled corticosteroids do have concerning effects on bone — although so far, the research suggests that they’re relatively small. When it comes to fracture risk, using these medications won’t by themselves put you at risk — but, you need to take into consideration the full range of fracture risks you’re facing, since even a slight increase could be the “straw that broke the camel’s back” if you’ve got a lot of other factors.

Treat the problem, not the symptom

But here’s the thing — if you’re using an inhaled corticosteroid regularly and for long periods of time, it indicates that you have chronic inflammation in your lungs, and likely throughout your body. We like to encourage folks to get to the root of the underlying problem — inflammation — through improved nutrition, exercise, and stress reduction. Reducing your symptoms is important, but treating the underlying inflammation will not only help reduce symptoms associated with asthma or COPD, it will also reduce your risk of bone loss and fracture. Since inhaled steroids are not risk-free when it comes to bone health, taking steps to limit your need for them only makes sense! 

On the flip side, it also makes sense to support your bones fully while you’re using these medications through an alkaline diet enhanced with nutritional supplements. Our Better Bones Builder is designed to offer the full range of vital, bone-supporting nutrients you need.

Liu Y, Dimango E, Bucovsky M, et al. Abnormal microarchitecture and stiffness in postmenopausal women using chronic inhaled glucocorticoids. Osteoporos Int. 2018 Sep;29(9):2121-2127. doi: 10.1007/s00198-018-4591-9. Epub 2018 Jun 11.

Loke YK, Gilbert D, Thavarajah M, et al. Bone mineral density and fracture risk with long-term use of inhaled corticosteroids in patients with asthma: systematic review and meta-analysis. BMJ Open. 2015 Nov 24;5(11):e008554. doi: 10.1136/bmjopen-2015-008554.

Loke YK, Cavallazzi R, Singh S. Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies. Thorax. 2011 Aug;66(8):699-708. doi: 10.1136/thx.2011.160028. Epub 2011 May 20.

Mohn ES, Kern HJ, Saltzman E, et al. Evidence of Drug–Nutrient Interactions with Chronic Use of Commonly Prescribed Medications: An Update. Pharmaceutics. 2018 Mar; 10(1): 36. Published online 2018 Mar 20. doi:  10.3390/pharmaceutics10010036

Sarwar G, Bisquera A, Peel R, et al. The effect of inhaled corticosteroids on bone mineral density measured by quantitative ultrasonography in an older population. Clin Respir J. 2018 Feb;12(2):659-665. doi: 10.1111/crj.12576. Epub 2016 Nov 10.

Seggev JS. Review: Long-term use of inhaled corticosteroids increases fracture risk in COPD. Ann Intern Med. 2012;156:JC3–7. doi: 10.7326/0003-4819-156-6-201202210-02007

Sidoroff VH, Ylinen MK, Kröger LM, et al. Inhaled corticosteroids and bone mineral density at school age: A follow‐up study after early childhood wheezing. Pediatr Pulmonol. 2015; 50:1–7.

Sutter SA, Stein EM. The skeletal effects of inhaled glucocorticoids. Curr Osteoporos Rep. 2016 Jun;14(3):106-13. doi: 10.1007/s11914-016-0308-1.