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 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.

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 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.