Advair and Bone Mineral Density

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Advair and Bone Mineral Density

Question:

I am a 57-year-old woman. Should I be concerned about taking Advair because of its effect on bone mineral density?

Answer:

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.

A recent study found that the benefits of salmeterol/fluticasone therapy in people who have poorly controlled asthma outweighed the risks, even taking into considering the effects of the drugs on bone density and fracture risk.

You can lessen the small increased risk of fractures associated with salmeterol/fluticasone by:

• Not smoking

• Avoiding excessive alcohol (more than one drink per day for women or two drinks per day for men)

• Exercising regularly with weight-bearing activities

• Working with your doctors to find the lowest effective dose of Advair

• 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 alendronate (Fosamax) or risedronate (Actonel). These medicines can increase bone mass and lower fracture risk. They are usually 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.

Robert Shmerling, M.D., is associate physician and clinical chief of rheumatology at Beth Israel Deaconess Medical Center and an associate professor in medicine at Harvard Medical School. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program and has been a practicing rheumatologist for over 25 years.

Last updated:	July 20, 2009