ASSOCIATION BETWEEN INHALED CORTICOSTEROID — USE AND BONE FRACTURE IN CHILDREN WITH ASTHMA

FCAAIA Notes: This is one of many studies showing the safety of inhaled steroids. Inhaled steroids have always been the first choice for persistent asthma. Their safety and negligible risk for side effects far outweighs the risks of poorly controlled asthma. In fact, this study also shows that oral steroids (the treatment of choice for significant asthma flares) are a risk factor for fracture.

The most common concern we hear about inhaled steroids is growth suppression in pre- and early adolescents.  In fact, even those data are so weak that they are only a concern in those (extraordinarily rare) patients who already had significant growth suppression while on the medications. Those same studies usually fail to report that poorly controlled asthma with or without oral steroid bursts can also suppress growth rates. Long-term use of inhaled steroids has NEVER been shown to result in a decrease in predicted adult height. Many older studies show that short-term growth suppression can occur in the first few months of use, but there is parallel and catch-up growth with continued use. We might therefore conclude that starting and stopping inhaled steroids is potentially more of a risk top growth than continued use!

We still recommend that patients brush their teeth (swish/spit) after using inhaled steroids and we always try to maintain the best possible control of asthma with as little medication as is necessary to do so.

(Source: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2661821 Nov. 18, 2017).

Question  Is use of inhaled corticosteroids associated with an increased risk of bone fracture in children with asthma?

Findings  In this population-based nested case-control study, no significant associations between current, recent, or past use of inhaled corticosteroids and first fracture after asthma diagnosis were observed in children with asthma, controlling for age, sex, age at asthma diagnosis , sociodemographic factors, and systemic corticosteroid use.

Meaning  Use of inhaled corticosteroids for the treatment of pediatric asthma should not be limited based  on fear of fracture.

Abstract

Importance  Daily use of inhaled corticosteroids is a widely recommended treatment for mild persistent asthma in children. There is concern that, similar to systemic corticosteroids, inhaled corticosteroids may have adverse effects on bone health.

Objective  To determine whether there is an increased risk of bone fracture associated with inhaled corticosteroid use in children with asthma.

Design, Setting, and Participants  In this population-based nested case-control study, we used health administrative databases to identify a cohort of children aged 2 to 18 years with a physician diagnosis of asthma between April 1, 2003, and March 31, 2014, who were eligible for public drug coverage  through the Ontario Drug Benefit Program (Ontario, Canada). We matched cases of first fracture after asthma diagnosis to fracture-free controls (ratio of 1 to 4) based on date of birth (within 1 year), sex, and age at asthma diagnosis (within 2 years). We used a 1-year lookback period to ascertain history of inhaled corticosteroid use. Multivariable conditional logistic regression was used to obtain an odds ratio (OR) with 95% confidence interval for fracture, comparing no inhaled corticosteroid use vs current, recent, and past use.

Exposures  Inhaled corticosteroid use during the child’s 1-year lookback period, measured as current user if the prescription was filled less than 90 days prior to the index date, recent user (91-180 days), past user (181-365 days), or no use

Main Outcomes and Measures  First emergency department visit for fracture after asthma diagnosis, identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes.

Results  This study included 19 420 children (61.0% male; largest proportion of children, 31.5%, were aged 6-9 years at their index date). The multivariable regression results did not show a significant association between first fracture after asthma diagnosis and current use (OR, 1.07; 95% CI, 0.97-1.17), recent use (OR, 0.96; 95% CI, 0.86-1.07), or past use (OR, 1.00; 95% CI, 0.91-1.11) of inhaled corticosteroids, compared with no use, while adjusting for sociodemographic factors and other medication use. However, use of systemic corticosteroids in the 1-year lookback period resulted in greater odds of fracture (OR, 1.17; 95% CI, 1.04-1.33).

Conclusions and Relevance  Systemic corticosteroids, but not inhaled corticosteroids, were significantly associated with increased odds of fracture in the pediatric asthma population.

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