Can asthma treatment affect bone health?
Ask the doctor
Q. I am a 57-year-old woman. Should I be concerned about taking Advair because of its effect on bone mineral density?
A. Advair is an inhaled medication that combines salmeterol and fluticasone. It's often prescribed for asthma and other lung diseases.
Salmeterol is a beta agonist. It helps open up airways. Tight airways are a problem in asthma and chronic obstructive pulmonary disease (COPD). That's why beta agonists are one of the first-line treatments.
Fluticasone is a corticosteroid. It suppresses inflammation in the airways. That's important because airway inflammation plays an important role in asthma and COPD. Inhaled corticosteroids are often prescribed for people with moderate to severe asthma or related breathing disorders.
Although inhaled corticosteroids have most of their effects in the airways, some medication is absorbed into the bloodstream. This exposes the entire body to their side effects.
In general, corticosteroids tend to lower bone mineral density. This is a measure of bone strength and fracture risk. This risk is greatest when a person takes high doses of corticosteroids for a long time.
While the results of studies are mixed, it appears that Advair and other inhalers that contain fluticasone can lower bone mineral density and increase the risk of fractures. The good news is that the effect is generally small.
This potential problem may be most important for people with other risk factors for osteoporosis. These include smoking, advanced age, a family history of osteoporosis, and a lack of weight-bearing exercise. The effect is largest for people taking high doses of inhaled steroids who also have other risk factors.
Studies suggest that the benefits of salmeterol/fluticasone therapy in people with poorly controlled asthma outweigh the risks, even after taking into account the effects of the drugs on bone health.
You may be able to lessen the impact of salmeterol/fluticasone on bone mineral density by
- not smoking
- avoiding excessive alcohol
- exercising regularly with weight-bearing activities
- working with your doctors to find the lowest effective dose of Advair (or even stopping it if your doctor feels that’s a safe option for you)
- getting bone mineral density tests (for example, every two to three years)
- having your thyroid checked (because an overactive thyroid or too much thyroid medication can lower bone mineral density)
- taking calcium and vitamin D (especially if you don't get much in your diet)
- possibly taking a medicine that can build bone and reduce fracture risk, such as alendronate (Fosamax) or risedronate (Actonel). These medicines are usually prescribed for people who take oral corticosteroids, have falling or low bone mineral density, or have had at least one osteoporotic fracture in the past.
Review your treatment options with your doctor. Be sure you understand why you were prescribed salmeterol/fluticasone and what alternatives are available to you.
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About the Author
Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
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