Effect of fracture risk in inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Abstract

Background: The fracture risk of patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids is controversial. And some large-scale randomized controlled trials have not solved this problem. The purpose of our systematic review and meta-analysis including 44 RCTs is to reveal the effect of inhaled corticosteroids on the fracture risk of COPD patients. Methods: Two reviewers independently retrieved randomized controlled trials of inhaled corticosteroids or combinations of inhaled corticosteroids in the treatment of COPD from PubMed, Embase, Medline, Cochrane Library, and Web of Science. The primary outcome was a fracture event. This study was registered at PROSPERO (CRD42022366778). Results: Forty-four RCTs were performed in 87,594 patients. Inhaled therapy containing ICSs (RR, 1.19; 95%CI, 1.04–1.37; P = 0.010), especially ICS/LABA (RR, 1.30; 95%CI, 1.10–1.53; P = 0.002) and triple therapy (RR, 1.49; 95%CI, 1.03–2.17; P = 0.04) were significantly associated with the increased risk of fracture in COPD patients when compared with inhaled therapy without ICSs. Subgroup analyses showed that treatment duration ≥ 12 months (RR, 1.19; 95%CI, 1.04–1.38; P = 0.01), budesonide therapy (RR, 1.64; 95%CI., 1.07–2.51; P = 0.02), fluticasone furoate therapy (RR, 1.37; 95%CI, 1.05–1.78; P = 0.02), mean age of study participants ≥ 65 (RR, 1.27; 95%CI, 1.01–1.61; P = 0.04), and GOLD stage III(RR, 1.18; 95%CI, 1.00–1.38; P = 0.04) were significantly associated with an increased risk of fracture. In addition, budesonide ≥ 320 ug bid via MDI (RR, 1.75; 95%CI, 1.07–2.87; P = 0.03) was significantly associated with the increased risk of fracture. Conclusion: Inhalation therapy with ICSs, especially ICS/LABA or triple therapy, increased the risk of fracture in patients with COPD compared with inhaled therapy without ICS. Treatment duration, mean age of participants, GOLD stage, drug dosage form, and drug dose participated in this association. Moreover, different inhalation devices of the same drug also had differences in risk of fracture.