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Inhaled corticosteroids (ICS) negatively affect bone mineralization, but ICS effects on fracture risk in patients with chronic obstructive pulmonary disease (COPD) are unknown. Researchers used a Quebec database to analyze hip or upper-extremity fractures in 240,000 COPD patients (age, ≥55).
In a nested, case-control analysis, each patient with fracture (≈19,000) was matched to 20 control patients. During an average 5.3 years of follow-up, no overall excess fracture risk was detected in patients who received ICS; however, patients who received high-dose ICS (equivalent to 1000-μg fluticasone) for longer than 4 years experienced 10% more fractures than did controls. Twenty fractures occurred per 1000 women annually, whereas 9 fractures occurred per 1000 men annually; relative fracture risk due to ICS was not different in women versus men.
Gonzalez AV et al. Long-term use of inhaled corticosteroids in COPD and the risk of fracture. Chest 2018 Feb; 153:321. (https://doi.org/10.1016/j.chest.2017.07.002)
Cho YJ and Sin DD.Inhaled corticosteroids and fractures in COPD: Can we finally put this to bed? Chest 2018 Feb; 153:293. (https://doi.org/10.1016/j.chest.2017.08.027)
Comment
This study suggests a modest excess risk for fractures in COPD patients who receive long-term ICS. In an accompanying editorial, the authors point out that more than 60% of COPD patients who are treated with ICS probably don't need them. Along with the excess risk for pneumonia seen in some fluticasone studies, this excess fracture risk should encourage us to follow the GOLD guidelines and reserve ICS for patients who still experience exacerbations while using dual long-acting bronchodilators (NEJM JW Gen Med Jun 15 2017 and Am J Respir Crit Care Med 2017; 195:557). In fact, in a recent randomized trial, ICS-containing triple therapy lowered the incidence of exacerbations (compared with dual bronchodilator therapy) in such patients (NEJM JW Gen Med Mar 15 2018 and Lancet 2018 Feb 8; [e-pub]).