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Background: Understanding the potential deleterious effects of corticosteroids on bone health in people with asthma is important when making treatment decisions. There is a need for clearer evidence to better quantify the risk and effect size., Methods: Databases were systematically searched to identify studies reporting on bone mineral density (BMD) measurement and risk of osteoporosis or fracture, comparing people with asthma exposed to inhaled (ICS) or oral (OCS) corticosteroids, with nonexposed people with asthma and healthy controls. Data were narratively synthesized, and a series of meta-analyses were performed using the random-effects inverse variance method., Results: This review consists of 28 studies (six randomized control trials and 22 observational). There was no effect of ICS on bone loss both at spine and femoral neck in asthma. People with asthma receiving OCS were at greater risk of osteoporosis than nonexposed people with asthma (pooled HR = 1.76; 95%CI: 1.48 to 2.09; I 2 =68%). Similarly, higher ICS exposure was associated with higher risk of osteoporosis (OR = 1.63; 95%CI: 1.33 to 1.99) and fracture (pooled OR = 1.19; 95%CI: 1.05 to 1.35; I 2 =0%) when comparing people with asthma receiving ICS and not., Conclusion: Patients with asthma exposed to OCS or high ICS doses become more susceptible to bone comorbidities. Striking the right balance between efficacy and safety of steroids in asthma is important to improve patients' quality of life., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Osteoporosis and fragility fractures are associated with corticosteroids which are the mainstay treatment for asthma; however, these bone comorbidities within asthma need to be better described., Methods: A matched cohort study was conducted using the UK Clinical Practice Research Database (CPRD). Adults with an incident asthma code were identified and matched, with up to four randomly selected people without asthma, by age, sex and practice. Osteoporosis and fragility fracture incidence rates were calculated, and Cox regression was performed comparing hazard rates to the general population. We report the impact of age, sex, glucocorticoids and the risk of specific fractures., Results: Patients with asthma had a higher risk of osteoporosis (adjusted hazard ratio (aHR) 1.18, 95% CI 1.13-1.23) and were 12% (aHR 1.12, 95% CI 1.07-1.16) more likely to sustain fragility fractures than the general population. Age modified the effect of asthma on osteoporosis and fragility fractures, such that the effect was stronger in younger people (p interaction <0.0001). The vertebra (aHR 1.40, 95% CI 1.33-1.48) and forearm/wrist (aHR 1.27, 95% CI 1.22-1.32) were the sites linked with a larger incidence. A dose-response relationship between oral corticosteroids (OCS) and osteoporosis was observed, whereas the risk of fragility fractures increased in those with six or more OCS courses per year. Regular use of inhaled corticosteroids (ICS) increased the risk of both bone conditions., Conclusions: Patients with asthma are more likely to develop osteoporosis or sustain fragility fractures than the general population, with a particular concern in younger people and those more frequently using OCS and ICS., Competing Interests: Conflict of interest: C.V. Chalitsios has nothing to disclose. Conflict of interest: T.M. McKeever has nothing to disclose. Conflict of interest: D.E. Shaw has nothing to disclose., (Copyright ©ERS 2021.)

Introduction: Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD., Methods: A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like., Results: The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required., Conclusion: There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required., Competing Interests: SH is funded for 1 session per month to work as a clinical commissioner for respiratory in Somerset CCG and works as a general practitioner partner in Somerset (five sessions per week). He is also a member of the NHS England Cardiovascular and Respiratory Programme Strategic Board and has worked as an unpaid advisor for the British Lung Foundation and Royal College of General Practitioners at a national level. KL owns a share in Primary Integrated Community Service (PICS) that employs respiratory nurses in the community and is also the medical director of PICS. JS has no direct conflict of interest with this publication but has received support or honorarium from Astra Zeneca, Nutricia, ARNS, Chiesi, Mundipharma, ROCHE, Boehringer Ingelheim, Teva, PCRS-UK, MIMS, Mark Allen Group, ADMIT, NIP and Mylan. Prof. CEB reports grants from British Lung Foundation, during the conduct of the study. All authors declare they have no other conflicts of interest in relation to this article., (© 2020 Gupta et al.)

Exposure to oral corticosteroids (OCS) is associated with an increased risk of osteoporosis and fragility fractures. Guidelines suggest bisphosphonate (BP) therapy as the first-line treatment of glucocorticoid-induced osteoporosis (GIOP). This population study used publicly available data, including prescription annual cost analysis and monthly practice-level data. Our aim was to examine the prescribing of OCS and BP at practice level and investigate reasons for variation using a mixed-effect negative binomial regression analysis. There was a rise in OCS and BP prescriptions of 55% and 1200% from 1998 to 2018, respectively. Of the 6586 included practices, the median (IQR) of OCS and BP prescriptions were 120.8 (84.8-160.4) and 107.7 (73.8-147.4) per 1000 patients, respectively. Asthma and chronic obstructive pulmonary disease (COPD) were significantly associated with OCS use (p < 0.0001), but only COPD was associated with BP use (p < 0.0001). Higher OCS prescribing rates were associated with higher BP prescribing rates (5th to 1st quintile-IRR = 1.99; 95% CI: 1.88-2.10). Practice list size, deprivation and advanced age were all associated with both drugs (p < 0.0001). In conclusion, although OCS use is positively associated with BP prescription, variation among practices and CCGs exists. The variation in prescribing suggests there is still a need to improve GIOP prevention.