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Asthmatics on glucocorticoid therapy are two to twenty times as likely to develop osteoporosis as asthmatics who are not. But changing the way these drugs are used can greatly reduce the risk of bone disease.

"Steroid" medications are a mainstay of asthma treatment. Glucocorticoid pills and inhalers reduce the inflammation that tightens air passages and make breathing easier. The downside of these very popular medications is that they have a negative impact on bone health. They reduce the number and activity of the bone-building cells known as osteoblasts, and accelerate the life cycle of osteoblasts so that they die prematurely. They also cause stem cells destined to become bone-making osteoblasts to develop into fat cells, which weaken bone rather than strengthening it.

It can take as little as six months for asthma medications to do measurable damage to bone. There is increased risk of fractures in the spine and hip during the first year of asthma treatment. This drug-induced secondary osteoporosis can strike anyone, of either sex, at any age. One study found that high-dose glucocorticoids in children caused spinal fracture rates of up to 45 percent. (Particular problems were found with Deflazacort, prednisolone, and prednisone. That doesn't mean that you should take your child off these medications, but consultation with the doctor about preventing bone problems when children are given these medications is a must.) Osteoporosis from asthma medications has even been observed in children. However, it is not necessary to suffer asthma to lower your risk of treatment-related osteoporosis.

Glucorticoid asthma medications elevate the risk of osteoporosis, but there are ways of taking them that reduce that risk. If you are on an inhaler for asthma, here are 10 things you need to know to help keep your risk of brittle bones to a minimum.

1. Inhaled glucocorticoids do less damage to bone than oral glucocorticoids

One study even concludes that inhaled glucocorticoids pose no additional risk of osteoporosis for people who have asthma and chronic obstructive pulmonary disease. One thing is for sure: You'll put less stress on your bones if you take your asthma medication by inhaler. Just be sure to limit the number of times you use your inhaler to the number of times permitted by your prescription.

These safer, inhaled, asthma medications include:

  • Beclomethasone dipropionate (Qvar)
  • Budesonide (Pulmicort)
  • Budesonide/Formoterol (Symbicort) 
  • Fluticasone (Flovent)
  • Fluticasone inhzlable powder (Arnuity Ellipta)
  • Fluticasone/Salmeterol (Advair) 
  • Mometasone (Asmanex)
  • Mometasone/formoterol (Dulera) 

2. Anyone who experiences persistent hip, knee, or shoulder pain while taking asthma medication should be evaluated for both osteoporosis and osteonecrosis

Osteoporosis, demineralization of bone, is a common complication of certain asthma drugs. Osteonecrosis, death of bone, is a much rarer complication of treatment. But because osteonecrosis can pose life-threatening changes to bone, the possibility should be ruled out.

3. Anyone who takes glucocorticoid medications for asthma who has ever had a 'fragility fracture' should be evaluated for osteoporosis

Any history of a "too easy" bone fracture is a red warning flag for osteoporosis. This is especially true if the fracture occurs before the age of 50. For people under 50, a "bad" T score from the DXA scan is -2, not -2.5. Lower levels of bone demineralization in younger people are more alarming than higher levels of bone demineralization in older people.

4. If you take oral steroid medication for asthma, the standard recommendation is that you should also be on bisphosphonates

The American College of Rheumatology recommends that anyone who takes oral asthma medication of the glucocorticoid class also be put on supplemental calcium and vitamin D plus prescription bisphosphonates to maintain bone mineral density. It's important to keep in mind, however, that bisphosphonates are not something anyone should take indefinitely. They act in a way that is similar to stacking bricks without any mortar to hold them together. They encourage new mineral content without encouraging the collagen network that holds bone minerals in form. Usually, bisphosphonate therapy should be reconsidered at least every two years. However, there are alternatives to glucocorticoids for asthma.

5. Some of the risk factors for osteoporosis faced by asthmatics who use inhalers are controllable

Smoking, excessive drinking, and a diet deficient in fruits and vegetables are detrimental in both asthma and osteoporosis. It's almost always possible to smoke less and to avoid binge drinking, and nutritional issues can be addressed by changes in diet and supplementation.

  • Astaxanthin, a pigment found in many "red meat" fish, is helpful in managing both asthma and osteoporosis. Try eating wild salmon a couple times a week, or take an supplement that includes astaxanthin.
  • Magnesium deficiencies are common in both asthmatics and people who have osteoporosis. Making a point of eating leafy greens every day and taking 200 to 600 mg of a magnesium supplement daily will help in managing both conditions.
  • Omega-3 essential fatty acid levels tend to be deficient in both asthmatics and people who have osteoporosis. It only takes about 1500 mg of DHA plus EPA daily to make a difference.
  • Vitamin D levels tend to be  lower in asthmatics. This is particularly true for women, and especially women who wear traditional Muslim dress. The solution is simple. Take 1000 to 2000 IU of vitamin D daily.

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  • Photo courtesy of SteadyHealth

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