Impact of Inhaled Corticosteroids on Osteoporosis in Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review

Inhaled corticosteroids (ICS) are commonly prescribed for chronic obstructive pulmonary disease (COPD) management, but their long-term use has been associated with potential adverse effects on bone health, including osteoporosis and fractures. This systematic review aimed to evaluate the impact of ICS on osteoporosis and fracture risk in COPD patients by synthesizing evidence from observational and clinical studies. A comprehensive literature search was conducted across PubMed, Web of Science, Scopus, Embase, and the Cochrane Library, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were screened for eligibility based on predefined inclusion criteria, and data were extracted using a standardized form. The Newcastle-Ottawa Scale (NOS) was employed to assess the risk of bias in included studies. Due to heterogeneity in study designs and outcome measures, a narrative synthesis was performed, focusing on key themes such as dose-response relationships, fracture risk, and the influence of ICS duration. Eleven studies were included, revealing mixed findings on the association between ICS use and bone health outcomes. While some studies reported a dose-dependent increase in osteoporosis incidence and fracture risk, others found no significant association or even protective effects in specific subgroups. High-dose and long-term ICS use were consistently linked to greater risks, particularly in vulnerable populations such as elderly and female patients. The methodological quality of studies varied, with most demonstrating low to moderate risk of bias. This review highlights the complex relationship between ICS use and bone health in COPD patients, emphasizing the importance of individualized treatment approaches. While ICS remain essential for COPD management, clinicians should consider bone-protective strategies in high-risk patients, particularly those on long-term or high-dose regimens. Future research should standardize exposure and outcome definitions to facilitate more robust quantitative synthesis.