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Original Investigation
January 2018

Association Between Inhaled Corticosteroid Use and Bone Fracture in Children With Asthma

Author Affiliations
  • 1The Hospital for Sick Children, Toronto, Ontario, Canada
  • 2Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
JAMA Pediatr. 2018;172(1):57-64. doi:10.1001/jamapediatrics.2017.3579
Key Points

Question  Is use of inhaled corticosteroids associated with an increased risk of bone fracture in children with asthma?

Findings  In this population-based nested case-control study, no significant associations between current, recent, or past use of inhaled corticosteroids and first fracture after asthma diagnosis were observed in children with asthma, controlling for age, sex, age at asthma diagnosis, sociodemographic factors, and systemic corticosteroid use.

Meaning  Use of inhaled corticosteroids for the treatment of pediatric asthma should not be limited based on fear of fracture.


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, Setting, and Participants  In this population-based nested case-control study, we used health administrative databases to identify a cohort of children aged 2 to 18 years with a physician diagnosis of asthma between April 1, 2003, and March 31, 2014, who were eligible for public drug coverage through the Ontario Drug Benefit Program (Ontario, Canada). We matched cases of first fracture after asthma diagnosis to fracture-free controls (ratio of 1 to 4) based on date of birth (within 1 year), sex, and age at asthma diagnosis (within 2 years). We used a 1-year lookback period to ascertain history of inhaled corticosteroid use. Multivariable conditional logistic regression was used to obtain an odds ratio (OR) with 95% confidence interval for fracture, comparing no inhaled corticosteroid use vs current, recent, and past use.

Exposures  Inhaled corticosteroid use during the child’s 1-year lookback period, measured as current user if the prescription was filled less than 90 days prior to the index date, recent user (91-180 days), past user (181-365 days), or no use.

Main Outcomes and Measures  First emergency department visit for fracture after asthma diagnosis, identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes.

Results  This study included 19 420 children (61.0% male; largest proportion of children, 31.5%, were aged 6-9 years at their index date). The multivariable regression results did not show a significant association between first fracture after asthma diagnosis and current use (OR, 1.07; 95% CI, 0.97-1.17), recent use (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 with no use, while adjusting for sociodemographic factors and other medication use. However, use of systemic corticosteroids in the 1-year lookback period resulted in greater odds of fracture (OR, 1.17; 95% CI, 1.04-1.33).

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