Corticosteroid And Bone Mineral Density In Patients example essay topic

Research Synthesis Paper According to American Academy of Pediatrics, "It is estimated that approximately 15 million people in the United States suffer from Asthma. Asthma is the most common chronic illness in children" (Schlienger 2004). Although inhaled steroids have been established as the preventive treatment of choice, few studies have been conducted to assess the risks of inhaled steroid therapy. Inhaled corticosteroids are absorbed into the systemic circulation, but the extent to which they have adverse effects on bone density and growth is uncertain. The question is important since according to A AOP, "10% of the American population take an inhaled corticosteroid regularly and may do so for many years" (2005). In the present paper the role that inhaled steroids have on growth and bone density of children is investigated.

Current guidelines recommend the use of inhaled corticosteroids for children and adolescents with mild persistent or more severe forms of asthma claiming they are safer then oral steroids. According to the American Academy of Pediatrics, "Inhalation targets corticosteroids directly to the site of airway inflammation with fewer adverse effects compared with oral administration. However, a considerable portion of an inhaled steroid dose is deposited in the oro pharynx and subsequently swallowed and absorbed from the gastrointestinal tract. Some fraction will be bio available to the systemic circulation, thereby potentially increasing the risk of adverse systemic corticosteroid effects" (Napoli, 2001).

In the Healthy People 2010 report, the goal concerning respiratory diseases is to "promote respiratory health through better prevention, detection, treatment, and education". Effective health management strategies for meeting this goal include: "controlling factors that trigger asthma, such as upper-respiratory infections, allergens, food or drug allergies, emotional upset, irritants, and exercise; use pharmacologic intervention tailored to the severity of the disease; provide objective monitoring of lung function; and educate patients with asthma to become active participants in their own care" (HP, 2000). This relates to this topic because education is very important in caring for a patient with asthma. The patient should be taught how to use the and possible side effects that can occur. It is also important to teach patients how to reduce the incidence of asthma so the use of might not be needed. Through my research I learned that studies investigating the association between inhaled corticosteroid use and bone-mineral density in adults have given inconsistent results.

These studies have been small, the duration of treatment has been short, and most have been confounded by patients' previous use of oral corticosteroids. Most of the research conducted on this topic contradicted itself therefore; it was hard to walk away from the research with a sense of accomplishment or confidence. Some of the research said that there was a correlation between bone loss, delayed growth and inhaled while some research did not agree. The following five literature reviews investigate this topic. Some articles attempt to demonstrate and support the safety behind inhaled while some articles challenge this claim, claiming the negative side effects.

The first study by Raymond Schlienger, (2004) tried to determine whether children or adolescents who are exposed to inhaled are at higher risk of having bone fractures compared with non exposed. This was a case study that identified children aged 5-17 years with a fracture diagnosis and taking compared to the control group. This study concluded that exposure to inhaled steroids does not materially increase the fracture risk in children or adolescents compared with non exposed individuals. However, there are many limitations to this study including small sample size. The author of the study states, "Because of small sample size in the individual strata and, as a result of that, wide CIs, we cannot exclude with certainty that especially long-term exposure with inhaled corticosteroid might be associated with a slightly increased fracture risk".

The next study was conducted in 2000 and was written by Conroy Wong. This study was called: Inhaled corticosteroid use and bone-mineral density in patients with asthma. This study focused on the long term effects of and tested an older population. This study showed contradicted the study above claiming there was a correlation between bone loss and.

A total of 196 adult asthmatics between the ages of 20 and 40, with an average length of use of inhaled corticosteroids for six years and an average cumulative dose of 876 mg, had measurements taken at the lumbar spine and proximal femur. Cumulative dose of inhaled corticosteroid was calculated from questionnaires and computerized and written general-practice records, and its effect on bone-mineral density was estimated by multiple regression analysis. All showed a negative relationship between dosage and bone mineral density, and doubling the dose of inhaled corticosteroid was associated with a more significant decrease at the lumbar spine and femoral neck. This study provides evidence of a negative relation between total cumulative dose of inhaled corticosteroid and bone-mineral density in patients with asthma. The third article is enti lied, Local side effects of inhaled corticosteroids in the asthmatic child influence of drug, dose, age and device. Was written by Kirk Waibel.

Waibel conducted a study in children 4-17 years of age with asthma treated with inhaled 300-800 [micro] g / day for a mean of 25 months. During this 6-month longitudinal study he found that the change in vertebral bone mineral density in asthmatic children receiving inhaled did not differ significantly from non asthmatic controls. He concluded that, "bone mineral density did not significantly differ from that of age- and sex-matched controls measured by radiographic and bone mineral content measured by single-photon and dual-energy x-ray " (2002). Furthermore, serum levels of calcium, magnesium, zinc, total alkaline phosphatase, bone specific alkaline phosphatase, parathyroid hormone, 25-hydroxy vitamin D, and 1, 25- D were also not different from that of controls. The author states, "Overall, direct measurements of bone and of bone metabolism markers do not indicate that moderate doses of ICS affect bone density. More long-term studies of high-dose therapy and comparisons of different drugs are needed, however.

This is especially true for studies of the effects of ICS during the toddler years and adolescence, for which no information is currently available" (Merk us 2002). This article proves the idea that more research needs to be conducted in this area in order to conclude an accurate answer to the topic in question. The fourth journal to be reviewed was one entitled: Bone mineral density in subjects with mild asthma we randomized to receive inhaled, or non corticosteroid treatment for two years. The main outcome measure change in bone mineral density was measured after 6, 12, 24 months. Subjects treated with an inhaled corticosteroid has better asthma control then those in the control group. Change in bone density did not differ between the two groups over 2 years.

This article concluded that, "Repetitive use of inhaled corticosteroids to treat asthma exacerbations do not affect bone density, bone metabolism, or adrenal insufficiency over the long term and can be used safely" (Tatters field, 2001). The final review is an article written by David Allen entitled: Inhaled corticosteroid therapy for asthma in preschool children: growth issues (2002). In this article David Allen compared and contrast studies performed on this topic and summarized his finding. I chose to discuss this article last because I believe it was the article that gave the best explanation and made the most sense. He looked at the whole picture rather then just one cohort study. This article reviews normal early childhood growth physiology, including confounding variations in normal growth, mechanisms of-induced growth suppression, data concerning growth effects of ICS in general, and important differences that affect the ratio of therapeutic-to-systemic effects of individual ICS preparations.

From this information and the small amount of data available regarding ICS effects in infants and very young children, predictions regarding risk of ICS therapy on growth in children of preschool-age and challenges for future investigations are offered. According to David, "Normal childhood growth can be divided conceptually into 3 phases according to primary growth-supporting factors: nutrition-dependent growth of infancy, GH-dependent childhood growth, and sex steroid / GH stimulation of pubertal growth" (2002). He explains that susceptibility to -induced growth suppression appears to increase during periods of transition from one phase to another, particularly in the immediate pre pubertal years. "Studies using ICS at varying dosages demonstrate the possibility of short-term growth suppression, but long-term studies suggest a negligible effect, if any, on final adult height or bone mineral density.

Although certain speculations regarding the safety of ICS use in infants and very young children can be made based on these data, age-specific studies are needed to account for effects of differences in oral versus airway deposition and growth axis resiliency, which may occur in these patients" (2002). This reinstates the idea that more studies need to be conducted in the younger age group in order to conclude a correct answer. Several conclusions appear well-supported by studies of inhaled in school-aged pre pubertal children. According to the author, "ICS used in small dosages present no significant risk for systemic adverse effects. When ICS are used at higher dosages and continuously for long periods of time, important differences in drug characteristics, affect the ratio of therapeutic to systemic effects of individual ICS. Detectable suppression of childhood growth can occur when ICS with relatively poor first-pass inactivation are administered at doses of 400 [micro] g / day or greater" When I compared these findings to that of two text my findings were much the same, inconclusive.

Both texts contradicted themselves, however, both agreed that more research needs to be done in order to be conclusive. According to the manual of allergy and immunology in a study conducted by the childhood asthma management program research group where 4-6 year olds were studied. "Budesonide provided superior asthma control but at the expense of a small but statistically significant reduction in growth velocity during the first treatment year. Despite this result, there was no difference in final projected adult height or growth velocity at the end of the treatment " (Adelman, 2002). This study concluded that, "there was no difference in bone mineral density between groups during the treatment period" (Adelman 2002).

The text mentioned that increased fracture risk has been shown in some research, but data on inhaled steroid therapy are limited. "Although several studies in children or adolescents showed that inhaled steroid therapy does not have a significant effect on bone turnover or bone mineral density, some studies suggest a suppression of bone formation or negative effects on bone mineral density associated with long-term or moderate- to high-dose therapy" (Adelman 2002). The second text was the Oxford Textbook of Medicine. This text discussed a study performed on males and females between the age of 15-35 with asthma and compared done mineral density in 47 who had taken inhaled steroids In doses between 100-3000 ug / day for at least 5 years. The use of the inhaled corticosteroid was associated with a decrease in bone density. This study contradicts the other study found in a text.

Proving that there is a lot of opposing information in this topic. This study was done on an older population furthermore; the text mentioned that in order to conclude the effect on the younger population more studies would have to be done. Implications for nursing practice would include educating the parent in the use of and possible side effects. Identification and counseling for these potential effects may improve patient care and compliance. Recognition of potential local side effects and discussion with the family before medication initiation can promote better provider-patient relationships and hopefully improve medication compliance. While assessing a patient it would also be important for the nurse to know if that patient was on long-term at one time because that should impact the care the patient gets.

For example, a patient who was on corticosteroids is more at risk for falls and injury because of the decreased bone density. The nurse should also be teaching the patient how to prevent the use of corticosteroids by reducing the signs and symptoms of asthma. The nurse also has a role in the prevention of bone break down in the asthmatic patient. The nurse can do this by educating the patient and family on the importance of screening and taking calcium supplements if not contracted by the patients' condition. As with all drugs, the benefits have to be weighed against the risks, and inhaled corticosteroids are clearly highly effective in the control of asthma and reducing the need for oral corticosteroids. However, the research I conducted all suggests that the long-term use of higher doses may predispose to osteoporosis, and patients should therefore take the lowest dose that adequately controls their asthma.

Patients who need to take high doses of an inhaled corticosteroid long-term may need to consider prophylactic measures to prevent osteoporosis. The nurse should have a role in communicating with the physician to ensure that proper screening preventive measures are being taken. The risk of adverse effects can be minimized, "by using the lowest effective dosage, by limiting systemic availability of the drug through careful selection of the inhalation device and proper technique, by the adjunct use of alternative anti-inflammatory agents, and, when higher doses are required, by choice of inhaled medication" (Sami 2004). Monitoring of growth in children is a sensitive method of detecting significant inhaled corticosteroids systemic effects and can enhance a family's confidence in the safety of the medication. The patient and family are affected by all of this because many parents fear the use of and are refraining from using them because of the possible side effects. It is detrimental that the patient and family be fully educated.

According to an article written by Jane Salo dof about parent's fear of ICS the author states, "Two-thirds of parents surveyed knew corticosteroids are effective in controlling asthma. More than half believed regular use of inhalers could keep their children out of hospital emergency rooms. Nonetheless, the parents were afraid of adverse events associated with use of oral steroids. Indeed, the respondents who had experience with a corticosteroid were more fearful, despite being convinced the inhaled medicine works" (2004).

It is important that the patient is aware of the side effects so proper screening can be done. It is imperative that the patient get the lowest dose needed for effective treatment. Everything talked about concerning the nursing implications could also be related to the patient because he / she or the parent should be aware of what is going on concerning their care. Nursing diagnosis that could relate to this problem area would be: . Knowledge deficit related to parents fear of using steroids as evident by statements made in American Academy of Pediatrics journal article entitled: Parents may be fearful of therapy: more education needed...

Risk for Injury related to long term us of as evident by decreased bone density and high risk of osteoporosis. Two additional research able questions related to this topic could include: . What influence does a chronic illness like asthma have on a child's performance in school? What is the relationship between uses of inhaled to prevent respiratory distress as RSV in infants and delay in physical development as a child?