Inhaled Corticosteroids and Bone Health in Asthma, COPD and Asthma-COPD overlap Syndrome (ACOS): Fracture Risks and Protection Gaps

Abstract Background Inhaled corticosteroids (ICS) are cornerstone therapies for asthma and chronic obstructive pulmonary disease (COPD), but concerns persist about their impact on bone health. We evaluated dose-dependent ICS effects on fractures, osteoporosis, and bone protection practices in patients with asthma, COPD and asthma-COPD overlap syndrome (ACOS) who were admitted to medical teams through our Emergency Department over a 26 month period. Methods We analysed 338 patients (55 asthma, 266 COPD, 17 ACOS) from a single- centre cohort. Multivariable logistic regression models assessed associations between ICS doses (none, low, moderate, high) and bone outcomes (prior fractures, DEXA-confirmed osteoporosis), adjusting for age, gender, smoking, falls, and comorbidities. Bone protection use (vitamin D/calcium) was evaluated across ICS groups. Results The mean age was 67.4 years (±13.9), with 53.3% female. Most patients used ICS (67.2%), primarily low/moderate doses (40.8% low, 11.8% moderate). There was no direct ICS dose-response relationship with previous fractures. However, moderate (OR 2.66, 95%CI: 1.12–6.33) and high ICS doses (OR 3.79, 95%CI: 1.66–8.64) were linked to osteoporosis/fractures compared to non-users. Women over 60 years had significantly elevated risks (OR 5.15, 95%CI: 1.14–23.29). Despite 30% having prior fractures or osteoporosis, 70% lacked bone protection (vitamin D/calcium). Bone protection was more common in COPD patients (OR 3.55 vs. asthma), those with prior fractures (OR 2.89), or osteoporosis (OR 2.45). Smoking did not modify ICS effects on bone health. Conclusion We determined that higher ICS doses correlated with osteoporosis/fracture risks, particularly in older women, necessitating targeted bone health monitoring. There were suboptimal bone protection practices that highlighted care gaps in high-risk respiratory populations. We recommend balancing ICS benefits with proactive bone health strategies, including DEXA screening and supplementation, especially in older females and COPD patients and the need for longitudinal studies to confirm findings, as cross-sectional studies limit causal inferences.