Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the world, with the mainstay of treatment instigated in primary care.1
Prednisolone is used in the management of COPD exacerbations. The use of steroids is associated with a higher risk of bone fractures and osteoporosis-related events.2,3 While the aetiology of bone loss in this context is multifactorial, it is recognised that corticosteroid use is a significant contributing factor.3
National guidelines advocate for the risk assessment of osteoporosis in post-menopausal women and men >50 years of age with prolonged steroid use, with recommendations that subsequent bone protection should be offered to those deemed high risk. High-dose steroid regimens are considered >5 mg oral prednisolone daily for prolonged duration of use >3 months.4,5 Cumulative doses are easily surpassed by COPD patients receiving three acute prescriptions of steroids for exacerbations.
In our single urban GP practice, we conducted a retrospective case note analysis from 2018–2023 involving 131 patients. Alarmingly, only 12.5% had undergone osteoporotic risk assessment, despite significant steroid burden with doses ranging from 600–4000 mg annually.
Is such significant risk worth the reward? A 2023 European meta-analysis suggests it is not: treatment is ineffective, and clinicians accept significant harm for a marginal benefit, at best.6
Our clinicians are becoming immune to the risks of prednisolone prescriptions and are misaligned with national guidance. Prednisolone prescribing is becoming a habit rather than critical thought. We fear that we are not alone and urge clinicians to remain vigilant to the harms associated with steroid burden in some of our most vulnerable patients.
- © British Journal of General Practice 2024
