1

FREQUENCY OF OSTEOPOROSIS IN ASTHMATIC PATIENTS WHO RECEIVE INHALED CORTICOSTEROID

İlknur Başyiğit, Serap Argun Barış, Haşim Boyacı, Füsun Yıldız Kocaeli University Faculty of Medicine Chest Disease Department

2

Introduction

Asthma is a chronic inflammatory disease with reversible airway obstruction.

Inflammation causes bronchial smooth muscle

contraction and bronchial hyperreactivity.

Inhaled corticosteroids are the most effective and most frequently used antiinflammatory agents in the treatment of asthma.

3

Introduction

Osteoporosis is one of the important side effect of long term systemic corticosteroid treatment.

Pathophysiology of osteoporosis with corticosteroid treatment:

Decrease in new bone synthesis via the suppression of osteoblastic activity

Activation of bone resorption Inhibition of intestinal calcium absorption

4

Introduction

It is accepted that systemic side effects of inhaled corticosteroids (ICS) are minimal.

The effect of ICS in bone mineral densitometry is controversial in previous studies.

5

Aim

The aim of this study was to determine whether there was a difference in osteoporosis frequency between asthmatic patients who were on ICS treatment and not.

6

Methods

The patients who were followed-up in asthma outpatient clinic were included in the study.

Age, gender, disease and ICS treatment duration and dose were recorded.

Medical history and risk factors for osteoporosis were recorded.

Patients who were not received ICS were enrolled as control group.

7

Methods

Blood calcium, phosphate, alkaline phosphatase, parathormone and vitamin D levels were analyzed and bone mineral densitometry (BMD) was performed.

DXA (Dual- energy x ray absorptiometry) was used for vertebrae and femur bone mineral densitometry.

8

Methods

The results was standardized with t score according to race and gender.

t- score <-2.5 osteoporosis t- score <-1.5/-2.5 osteopenia

Femur and vertebrae BMD findings; normal, osteopenia osteoporosis.

9

Methods

Exclusion criteria:

Diagnosis or treatment of osteoporosis before ICS treatment

Use of oral corticosteroids in the previous 3 months

Diagnosis of COPD

10

Methods

Use of medication that is known as to effect

bone mineral densitometry such as

-Calcium

-Vitamine D -Calsitonin -Estrogen

- Anticonvulsant- Diuretics

İmmobilization

11

Results

44 female, 16 male totally 60 patients were included in the study.

Mean age was 51.7 ± 11 years -In female mean age was 51 ± 10.7 years -In male mean age was 53.5 ± 12.4 years

Duration of disease was 8.4 ± 4.3 years

Mean duration for ICS treatment was 15 months

12

Graphic-1: Groups according to inhaled corticosteroid dose

Patients were divided into 3 groups according to their ICS treatment dose;

high dose ICS (n:33), low-moderate dose ICS

(n:12) and non-user (n:15).

0

10

20

30

40

50

60

High dose ICS(n:33)

Low-moderatedose ICS (N:12)

Non-user (n:15)

ICS dose

13

Table-1: Demographic characteristics

High dose IKS

Moderate-low dose ICS

Non-user

n 33 12 15

Age, year 50.8 ± 10.4 47.4 ± 10.2 57.0 ± 12.0*

Duration of ICS, month

22.9 ± 14.5 29.0 ± 22.6 0

Vertebra BMD 15 N, 13 OP, 5 OS

2 N, 8 OP, 2 OS

1 N, 8 OP, 6 OS*

Femur BMD 19 N, 11 OP, 3 OS

8 N, 4 OP, 0 OS

7 N, 6 OP, 2 OS

N: Normal, OP: Osteopenia, OS: Osteoporosis

14

Results

There was no significant correlation between the duration of ICS and BMD femur, BMD vertebrae findings and t-scores.

15

Results

29 patients received budesonide, 16 patients received fluticazone propionate

There was no significant correlation between the pharmacological formulation of ICS and BMD femur, BMD vertebrae findings and t-scores.

16

Graphic-2: Asthma severity according to groups

0

5

10

15

20

25

High dose Moderate-low

dose

Non-user

Mild I ntermittantAsthma

Mild PersistantAsthma

Moderate PersistantAsthma

17

Table-2: PFT results according to groups

High dose Moderate-low dose

Non-user p

FVC 2.82 ± 0.8 3.49 ± O.87 2.65 ± 0.87 0.04

FVC % predictive

95 ± 12 111 ± 14 90 ± 9 0.005

FEV1 1.97 ± 0.64 2.52 ± 48 1.6 ± 0.7 0.05

FEV1 % predictive

77 ± 12.5 95 ± 15 62 ± 7.7 0.00

FEV1/FVC,%

68.7 ± 8.3 72.6 ± 6.7 59 ± 10 0.02

PEF 4.8 ± 1.33 6.03 ± 1.14 4.87 ± 1.9 0.02

PEF % predictive

74.8 ± 14.7 90 ± 13.6 71.6 ± 14.8 0.007

18

Table-3: Biochemical parameters

Minimum Maksimum Mean SD

Calcium 8.5 10.4 9.37 0.426

Phosphate 2.18 4.30 3.48 0.44

Alkaline phosphatase

45 146 85.18 31.94

Parathormone 16 281 60.69 38.57

Vitamin D 6.4 16.28 11.34 6.98

19

Results

No difference was found between male and female patients with respect to BMD test results.

20

Graphic-3: Vertebrae BMD findings according to gender

0

10

20

30

40

50

60

Normal Osteopenia Osteoporosis

Female

Male

21

Graphic-4: Femur BMD findings according to gender

0

10

20

30

40

50

60

70

Normal Osteopenia Osteoporosis

Female

Male

22

Table-4: Gender distribution and number of postmenopausal women in groups

High dose ICSn:33 %

Moderate-low dose

ICS n: 12

%

Non- user

n: 15 %

Male 5 15 2 17 9 60

Female 28 85 10 83 6 40

Postmenopausal

14 50 4 40 5 83

23

Results

23 of 44 women in the study were in postmenopausal period

While we investigated the effects of menopause in the findings of BMD; it was found that femur BMD findings (p=0.05) and t- scores (p=0.04) were significantly different in postmenopausal women compared to others.

24

Results

There was no difference in femur BMD findings and t scores among the groups.

In vertebrae BMD test; there were significantly lower t scores (p=0.01) and more frequent osteoporosis (p=0.01) in patients who were not on ICS treatment.

25

Table-5: Osteoporosis and t-score according to groups

FEMUR VERTEBRAE

Osteoporosis t score Osteoporosis t score

High dose ICS

3 (%9)   - 0.5 ± 1.3

5 (%15) -0.7 ± 1.6 

Moderate-low dose ICS

- (%0)  -0.5 ± 0.6 

2 (%16) -1.2 ± 1

Non-user 2 (%13)  -0.8 ± 1.2 6 (%40)* -1.8 ± 0.8*

26

Results

There was a significant correlation between the age and femur and vertebrae BMD findings. (p=0,04)

27

Conclusion

It was suggested that osteoporosis in asthmatic patients might not be related to the pharmacological formulation, dose and treatment duration of ICS.

The high osteoporosis frequency in patients who were not on ICS treatment might be explained by the age and postmenopausal changes of these patient population.