What are the recommendations for monitoring and mitigating the effects of Inhaled Corticosteroids (ICS) on bone density?

Monitoring and Mitigating ICS Effects on Bone Density

For patients on inhaled corticosteroids at recommended doses, routine bone density monitoring is not necessary, as clinically significant bone loss is uncommon; however, patients with major risk factors for osteoporosis should be monitored and receive calcium (800-1000 mg/day) plus vitamin D (800 IU/day) supplementation. 1

Risk Assessment Framework

The evidence distinguishes clearly between inhaled and systemic corticosteroids regarding bone effects:

• Low-to-medium dose ICS (e.g., budesonide ≤1.0 mg/day, fluticasone at guideline-recommended doses) show no frequent, clinically significant, or irreversible effects on bone mineral density in children or adults at recommended doses 2

• High-dose or prolonged ICS use may cause dose-dependent decreases in bone markers, though the clinical significance remains uncertain 3, 4

• The FDA label for budesonide specifically warns about reduction in bone mineral density with long-term administration and recommends monitoring patients with major risk factors for decreased bone mineral content 1

Who Requires Monitoring

Identify high-risk patients who warrant bone density surveillance:

• Patients with pre-existing risk factors: postmenopausal women, older age, low body mass index, smoking, lack of weight-bearing exercise 2
• Those requiring high-dose ICS (>1.0 mg/day budesonide equivalent) for extended periods 3
• Patients with concomitant oral corticosteroid use (current or previous) 2
• History of fractures or family history of osteoporosis 2

The British Society of Gastroenterology notes that patients with high FRAX scores (≥20% major fracture, ≥3% hip fracture), those under 40 with risk factors, or those receiving prolonged oral corticosteroids should have bone mineral density assessed 2

Preventive Interventions

Universal Measures for All ICS Users

Lifestyle modifications should be implemented regardless of bone density status:

• Smoking cessation 2
• Regular weight-bearing and muscle-building exercise (weight training, running) 2
• Reduction of excess alcohol intake 2
• Mouth rinsing after ICS use to minimize local effects 1

Supplementation Strategy

Calcium and vitamin D supplementation represents first-line prevention:

• Dosing: 800-1000 mg/day calcium plus 800 IU/day vitamin D 2
• This regimen prevents bone loss from the lumbar spine and forearm in corticosteroid users 2
• Particularly important for patients requiring any systemic corticosteroid courses 2

When to Consider Bisphosphonates

Antiresorptive therapy with bisphosphonates should be based on:

• Risk factors including decreased BMD, female gender, older age, postmenopausal status, and low body mass index 2
• For systemic corticosteroids: prednisone >7.5 mg daily for >3 months warrants calcium/vitamin D, with bisphosphonates based on BMD measurement and risk factors 2
• The 2017 ACR guideline provides specific algorithms for glucocorticoid-induced osteoporosis that can guide decisions for high-risk ICS users 2

Monitoring Approach

For high-risk patients on long-term ICS:

• Baseline bone mineral density measurement via dual-energy X-ray absorptiometry (DEXA) of lumbar spine and hip 2, 4
• Periodic reassessment based on initial findings and ongoing risk factors 1
• Laboratory evaluation including vitamin D levels, given that >50% of patients with respiratory disease in northern Europe are deficient 2

Special Populations

Children and adolescents: The CAMP study provides strong evidence that 4-6 years of ICS treatment at recommended doses does not affect BMD in children 2. Growth monitoring is more relevant than bone density screening in this population 2, 1

Cancer survivors: Those treated with cranial/spinal radiation, total body irradiation, or corticosteroids have increased risk and warrant bone density surveillance per international guidelines 2

Critical Caveats

• ICS are fundamentally different from oral corticosteroids: They do not cause the clinically important adverse effects on bone density, cortisol production, and glucose metabolism seen with equivalently effective doses of oral prednisone 2

• Dose matters: Effects are dose-dependent, with doses >1.0 mg/day more likely to show biochemical changes 3. Use the lowest effective dose 3

• Confounding factors: Previous oral corticosteroid use, disease severity, and other osteoporosis risk factors often confound studies showing ICS-related bone loss 2, 4

• Long-term uncertainty: While short-to-medium term studies are reassuring, cumulative effects over decades remain incompletely characterized 2

• A 2023 European cohort study found no significant association between long-term ICS use and osteoporosis in subjects >55 years, even with exposure >36 months 5