Do Inhaled Corticosteroids Cause Osteoporosis?

Do inhaled corticosteroids cause osteoporosis? A friend asked me this question a few weeks ago, and I thought it would be interesting to write about. After all, questions about side effects of inhaled steroids are not at all new to me. Also, this was a question that I really did not have an answer to when first asked!

Inhaled vs. systemic corticosteroids and side effects

Typically, when facing a query like this, I first think about how most of these questions regarding inhaled corticosteroids stem from what people know about the side effects of systemic (oral) corticosteroids. First, corticosteroids are typically used for management of inflammation, as we see in asthma. Systemic corticosteroids are taken in much higher doses than inhaled corticosteroids. Because the effects of systemic corticosteroids are not localized to the lungs like inhaled corticosteroids are, they are more likely to cause various side effects with both shorter- and longer-term use.¹

Despite both containing the word 'steroid' and both acting on inflammation, the side effects of these two different forms of medication don’t generally overlap. There is the exception of increased appetite leading to weight gain, which applies only to long-term or high-dose inhaled corticosteroids.¹

Otherwise, inhaled corticosteroids typically lead to only cough, sore throat, hoarseness, and oral thrush in regular doses. This differs greatly from the more whole-body (systemic) side effects of oral corticosteroids. These side effects include mood swings, water retention/swelling, high blood pressure, elevated blood sugar, changes in appetite (often increase but sometimes decrease), and other side effects associated with long-term use.¹

Osteoporosis from corticosteroid inhalers?

Osteoporosis is a decrease in bone mass or bone density, characterized as “bone loss”. While oral corticosteroids taken over long periods can lead to bone loss, it was established that the use of inhaled corticosteroids (ICS) at “conventional doses” for asthma and COPD did not appear to be associated with osteoporosis.²

A 2014 study confirms, “The risk of osteopenia and osteoporosis is negligible in patients receiving low to moderate dose ICS treatment,” though those taking ICS and requiring “rescue” use oral corticosteroids may be at greater risk for developing osteoporosis, osteopenia (pre-osteoporosis) and osteonecrosis (bone cell death). However, it is likely if you don’t have other risk factors for these conditions, you are likely at low risk for having bone problems linked to your inhaled steroid.³

Preventing osteoporosis

Though your inhaled corticosteroid likely isn’t putting you at greater risk, there are things you can do to prevent osteoporosis. In addition to appropriate calcium intake, one of the most important ways to prevent osteoporosis is to participate in weight-bearing and aerobic exercise. Balance training is also important in reducing the risk of falls and fall-induced fractures.⁴

As was drilled into my head in the course Physical Activity and Aging, taught by an osteoporosis expert, the more force you put on your bones, the better it is for them in the long term. The right kinds of force on bones, such as moderate levels of exercise, stimulates remodeling —a good thing.

Walking, swimming, biking, dancing, and aerobics are all good choices for people with and without osteoporosis. Running is also fine if you do not already have bone loss. However, over-exercising can lead to bone loss, so there is too much of a good thing in this case! Your doctor can provide you with more advice about preventing osteoporosis.

Have you had concerns about osteoporosis as a long-term side effect of inhaled corticosteroids? What have you done to address those concerns? Share your thoughts in the comments below or in our treatment forum.