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Association between inhaled corticosteroid use and bone fracture in children with asthma


Importance — Daily use of inhaled corticosteroids is a widely recommended treatment for mild persistent asthma in children. There is concern that, similar to systemic corticosteroids, inhaled corticosteroids may have adverse effects on bone health.

Objective — To determine whether there is an increased risk of bone fracture associated with inhaled corticosteroid use in children with asthma.

Design — In this nested case-control study, we utilized health administrative databases from 2003–2014 to identify a cohort of children with physician-diagnosed asthma. We matched cases of first fracture after asthma diagnosis to fracture-free controls (1:4) based on date of birth (within 1 year), sex and age at asthma diagnosis (within 2 years). We used a one-year lookback period to ascertain history of inhaled corticosteroid use. Multivariable conditional logistic regression was used to obtain an odds ratio with 95% confidence interval for fracture, comparing no inhaled corticosteroid use to current, recent and past use.

Setting — Population-based study in Ontario, Canada.

Participants — Children aged 2-18 years with a physician diagnosis of asthma between 2003 and 2014 eligible for public drug coverage through the Ontario Drug Benefit program.

Main Exposure — Inhaled corticosteroid use during the child’s one-year lookback period, measured as current use if prescription was filled <90 days prior to index date, recent user (91-180 days), past user (181-365 days), or no use.

Main Outcome and Measurements — First emergency department visit for fracture after asthma diagnosis, identified using ICD-10 codes.

Results — In the 19,420 children included, the multivariable regression results did not show a significant association between first fracture after asthma diagnosis and current (OR: 1.07, 95% CI: 0.97-1.17), recent (OR: 0.96, 95% CI: 0.86-1.07), or past use (OR: 1.00, 95% CI: 0.91-1.11) of inhaled corticosteroids, compared to no use, while adjusting for sociodemographic factors and other medication use. However, use of systemic corticosteroids in the year lookback period resulted in a significantly greater odds of fracture (OR: 1.17, 95% CI: 1.04-1.33).

Conclusion and Relevance — Systemic corticosteroids, but not inhaled corticosteroids, were significantly associated with an increased odds of fracture in the pediatric asthma population.



Gray N, Howard A, Zhu J, Feldman LY, To T. JAMA Pediatr. 2018; 172(1):57-64. Epub 2017 Nov 13.

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