Chronic Obstructive Pulmonary Disease

COPD: Bone Density (2008)

• Assessment
  What is the relationship between steroids and bone mineral density in people with COPD?

  • Conclusion

    Twelve studies regarding the relationship between steroids and bone mineral density in people with COPD were reviewed.  Four studies report significant associations of cumulative corticosteroid use (both oral and inhaled, >1000 mg) with changes in biochemical bone markers, decreased bone mineral density, and increased fracture risk.  However, six studies based on inhaled corticosteroid use for at least one year report conflicting findings.  Two studies support a significant association between COPD and bone mineral density and/or fracture risk independent of steroid use.  Further research on the relationship among the type, dose and duration of corticosteroid use, confounding variables and bone mineral density is needed.        

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between steroids and bone mineral density in people with COPD?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • de Vries F, van Staa TP, Bracke MSGM, Cooper C, Leufkens HGM, Lammers JWJ. Severity of obstructive airway disease and risk of osteoporotic fracture. Eur Respir J 2005;25:879-884.
      • Dinc M, Tchugunova Y, Dinc S, Cinarli B, Atasever T, Oz M.  Decreased osteocalcin levels in patients with chronic obstructive pulmonary disease using long-term inhaled beclomethosone diproprionate.  Metabolism 2001, 11:1336-1339.
        
      • DuBois EF, Roder E, Dekhuijzen PN, Zwinderman AE, Schweitzer DH.  Dual energy x-ray absorptiometry outcomes in male COPD patients after treatment with different glucocorticoid regimens.  Chest 2002;121(5):1456-63.
      • Halpern MT, Schmier JK, Van Kerkhove MD, Watkins M, Kalberg CJ.  Impact of long-term inhaled corticosteroid therapy on bone mineral density:  results of a meta-analysis.  Ann Allergy Asthma Immunol 2004;92(2):201-7.
      • Johnell O, Pauwels R, Lofdahl CG, Laitinen LA, Postma DS, Pride NB, Ohlsson SV.  Bone mineral density in patients with chronic obstructive pulmonary disease treated with budesonide Turbuhaler.  Eur Respir J 2002;19(6):1058-63.
      • Lung Health Study Group.  Effect of inhaled triamcinolone on the decline in pulmonary function in chronic obstructive pulmonary disease.  N Engl J Med 2000;343(26):1902-9. 
      • McEvoy CE, Ensrud KE, Bender E, Genant HK, Yu W, Griffith JM, and Niewoehner DE.  Association between Corticosteroid Use and Vertebral Fractures in Older Men with Chronic Obstructive Pulmonary Disease. American Journal of Respiratory Critical Care Medicine 1998;157:704–709.
      • Melton LJ, Patel A, Achenbach SJ, Oberg AL, Yunginger JW.  Long-term fracture risk following adult-onset asthma:  a population-based study.  Osteoporosis International 2004;15:311-316.
      • Scanlon PD, Connett JE, Wise RA, Tashkin DP, Madhok T, Skeans M, Carpenter PC, Bailey WC, Buist AS, Eichenhorn M, Kanner RE, Weinmann G, The Lung Health Study Research Group.  Loss of bone density with inhaled triamcinolone in Lung Health Study II.  American Journal of Respiratory and Critical Care Medicine 2004;170:1302-1309.
        
      • Struijs A, Mulder H.  The effects of inhaled glucocorticoids on bone mass and biochemical markers of bone homeostasis:  a 1-year study of beclomethasone versus budesonide.  Netherlands Journal of Medicine 1997;50:233-237.
        
      • Walsh LJ, Lewis SA, Wong CA, Cooper S, Oborne J, Cawte SA, Harrison T, Green DJ, Pringle M, Hubbard R, Tattersfield AE.  The Impact of Oral Corticosteroid Use on Bone Mineral Density and Vertebral Fracture. American Journal of Respiratory and Critical Care Medicine  2002;166:691-695. 
      • Yeh SS, Phanumas D, Hafner A, Schuster MW.  Risk factors for osteoporosis in a subgroup of elderly men in a Veterans Administration nursing home.  J Investigative Med 2002;50(6):452-7.
  • Search Plan and Results: COPD: Steroids and Bone Density 2006
     
  In people with COPD, what are the primary risk factors for the development of osteoporosis?

  • Conclusion

    Thirteen studies regarding the primary risk factors for the development of osteoporosis in people with COPD were reviewed.  People with COPD are at increased risk for osteoporosis and/or vertebral fractures, and the prevalence ranges from 25% to 60%.  Four studies support a positive correlation between low body weight and/or BMI with decreased bone mineral density in subjects with COPD.  Additional risk factors reported include older age, smoking, and corticosteroid use.  Emerging research reports associations between hypercapnia, vitamin D status and bone mineral density; further research is needed in these areas.   

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: In people with COPD, what are the primary risk factors for the development of osteoporosis?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Bolton CE, Ionescu AA, Shiels KM, Pettit RJ, Edwards PH, Stone MD, Nixon LS, Evans WD, Griffiths TL, Shale DJ. Associated Loss of Fat-free Mass and Bone Mineral Density in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2004;170(12):1286-1293.
      • de Vries F, van Staa TP, Bracke MSGM, Cooper C, Leufkens HGM, Lammers JWJ. Severity of obstructive airway disease and risk of osteoporotic fracture. Eur Respir J 2005;25:879-884.
      • Dimai HP, Domej W, Leb G, Lau KH. Bone Loss in Patients with Untreated Chronic Obstructive Pulmonary Disease is Mediated by an Increase in Bone Resorption Associated with Hypercapnia. J Bone Miner Res 2001;16:2132-2141.
      • Forli L, Halse J, Haug E, Biortuft O, Vatn M, Kofstad J, Boe J. Vitamin D deficiency, bone mineral density and weight in patients with advanced pulmonary disease. J Intern Med 2004;256:56-62.
      • Incalzi RA, Caradonna P, Ranieri P, Basso S, Fuso L, Pagano F, Ciappi G, Pistelli R. Correlates of osteoporosis in chronic obstructive pulmonary disease. Respir Med 2000;94:1079-1084.
      • Karadag F, Cildag O, Yurekli Y, Gurgey O. Should COPD patients be routinely evaluated for bone mineral density? J Bone Miner Metab 2003;21:242-246.
      • Katsura H, Kida K. A comparison of bone mineral density in elderly female patients with COPD and bronchial asthma. Chest 2002;122:1949-1955.
      • Melton LJ, Patel A, Achenbach SJ, Oberg AL, Yunginger JW.  Long-term fracture risk following adult-onset asthma:  a population-based study.  Osteoporosis International 2004;15:311-316.
      • Nishimura Y, Nakata H, Tsutsumi M, Maeda H, Yokoyama M.  Relationship between changes of bone mineral content and twelve-minute walking distance in men with chronic obstructive pulmonary disease:  a longitudinal study.  Internal Medicine 1997;36:450-453.
        
      • Papaioannou A, Parkinson W, Ferko N, Probyn L, Ioannidis G, Jurriaans E, Cox G, Cook RJ, Kumbhare D, Adachi JD.  Prevalence of vertebral fractures among patients with chronic obstructive pulmonary disease in Canada.  Osteoporos Int 2003;14:913-7. 
      • Soriano JB, Visick GT, Muellerova H, Payvandi N, Hansell AL.  Patterns of comorbidities in newly diagnosed COPD and asthma in primary care.  Chest 2005;128:2099-2107.
      • Szymanski P, Mosiewicz J, Myslinski W, Dzida G, Rymarz E.  The influence of chronic obstructive pulmonary disease on the occurrence rate and intensification of osteoporosis.  Annales Universitatis Mariae Curie Sklodowska 2002;57(1):187-95.
      • Yeh SS, Phanumas D, Hafner A, Schuster MW.  Risk factors for osteoporosis in a subgroup of elderly men in a Veterans Administration nursing home.  J Investigative Med 2002;50(6):452-7.
  • Search Plan and Results: COPD: Risk Factors for Osteoporosis in COPD 2006