Bone, 13, 285-288, (1992) Printed in the USA. All rights reserved.
Copyright
8756-3282192 $5.00 + .OO 0 1992 Pergamon Press Ltd.
Inhaled Beclomethasone Decreases Serum Osteocalcin in Postmenopausal Asthmatic Women H. PUOLIJOKI,’
K. LIIPPO,’
J. HERRALA,
J. SALM12
and E. TALA’
’ Department ofDiseases of the Chest. Turku University Central Hospital, SF-21540 Preitila, Finland * Departments of Medicine and 3Diseases of the Chest, Tampere University Hospital, SF-33520 Tampere, Finland Address for correspondence and reprints: H. Puolijoki, Department of Diseases of the Chest, Turku University Central Hospital,
SF-20520 Turku, Finland. Abstract
Materials and Methods
There are very few data as yet to quantify the effect of inhaled corticosteroids on bone metabolism, although the use of these drugs as a first-line treatment in bronchial asthma has widened. We determined the effect of three dose levels (200, 1000, 2000 &day, three weeks each) of inhaled beclomethasone on specific characteristics of bone metabolism in nine postmenopausal women with new asthma without any previous corticosteroid therapy. Significant decrease was noted in the mean serum morning osteocalcin concentration between the baseline and after nine weeks of beclomethasone (from 4.4 to 3.1 &I, p = 0.005). Significant increase in serum total and ionised calcium was found, although the parameters measuring bone resorption itself did not change. The results show that especially high-dose inhaled beclomethasone decreases serum osteocalcin in postmenopausal asthmatic women. Further studies are needed to assess the effects of inhaled beclomethasone, both on the ability of the osteoblasts to form bone matrix and on the density of bone during a longer treatment period on inhaled corticosteroids.
The study group comprised nine nonsmoking postmenopausal women (age range 54-66 years, mean 15 years postmenopausal) with newly diagnosed bronchial asthma. They had neither history of fractures nor any nutritional, metabolic, renal, or bone disease, and none had previously received inhaled or systemic corticosteroids for any indication; nor were they taking drugs affecting calcium or phosphate metabolism, and none had ever received estrogen or other hormone substitution. At every visit all patients were admitted to the in-patient ward. They were given thorough training in the use of inhaled drugs and the spacer, and were taught to brush the mouth and throat carefully after having administered the drug. All patients were allowed to use inhaled sympatomimetics to control their asthmatic symptoms. After two days of preparatory examinations, each patient started a low-collagen diet, which was continued to the sixth day. On the fifth day, 24-hour urine collection was started, and after the end of the collection on the sixth day at 7.30 a.m., study blood samples were taken, and the tetracosactrin test (Irwin & Barnes 1972) by SynactenR 250 pg performed (injected into muscle and serum cortisol measured before and after 60 minutes). However, the sample for serum evening cortisol value was taken at 7.30 p.m. on the fifth day. Each patient started beclomethasone (BecotideR metered dose inhaler) from the spacer (VolumaticR) as the sole corticosteroid throughout the study at a dose of 100 pg twice daily for three weeks, after which the patient was readmitted. She had already previously followed a low-collagen diet at home for two days. After 24-hour collection of urine, the blood samples and the ventilation examinations were taken. Thereafter, the beclomethasone dose was increased to 500 micrograms twice daily, and the measurements were repeated again after three weeks. In the final phase the patients took 1000 pg beclomethasone twice daily for three weeks, the recommended maximum daily dose (British Thoracic Society et al. 1990), and at the end the same measurements were repeated. Routine methods were used for the analysis of the usual blood values. Urine hydroxyproline was analysed using 4-chloro-7-nitrobenzofurazan as the derivisation reagent (Reed et al. 1988). Serum parathormone (PTH, Incstar), dehydroepiandrosterone (DHEA, Radioassay Systems Laboratories), estrone (Amersham), 17B-estradiol (Amersham), osteocalcin (Incstar), calcitonin (Amersham), and carboxyterminal propeptide of human type I procollagen (PICP, Farmos Diagnostica) values were mea-
Key Words: Asthma-Beclomethasone-Bone Inhaled corticosteroid-Osteocalcin-Osteoporosis.
gla-protein-
Introduction The effect of inhaled corticosteroids on bone metabolism is very important because of the widened use of these drugs as a firstline treatment in bronchial asthma. However, there are very few data as yet to quantify the risk of osteoporosis with inhaled corticosteroids, especially among postmenopausal women, who have an increased risk of osteoporosis on low-dose systemic corticosteroid therapy (Lukert & Raisz 1990). Pouw et al. (1991) noticed recently in healthy volunteers that high-dose inhaled beclomethasone decreases serum osteocalcin but does not affect its diurnal variation. Hodsman et al. (1991) found, also in healthy volunteers, that both oral prednisolone and inhaled budesonide induced dose-dependent reductions in serum osteocalcin. In response to calcitriol, serum osteocalcin increased in the budesonide-treated healthy subjects, but not among those administered prednisolone. We studied specific characteristics of calcium metabolism for three successive periods with three different dosages of inhaled beclomethasone among postmenopausal asthmatic women.
H. Fuolijoki et al.: Osteocalcin
286
(RIA) or immunoradiometric sured later by radioimmunoassay assay (IRMA) from the samples frozen to - 70” C immediately. The lncstar Osteocalcin RIA employed simultaneous addition of sample, rabbit antibovine osteocalcin antibody and “‘1 bovine osteocalcin, followed by an overnight incubation at 2”-8” C. Phase separation was accomplished by the addition of a complex of goat anti-rabbit serum and polyethylene glycol. The assay was centrifuged and decanted after a two-hour incubation at 2”-8” C. The minimum detectable amount was determined to be 0.2 p.gil. lntra-assay and interassay variations (CV) were determined to be around 2%. The radioimmunoassay of PICP was performed by docent Juha Risteli, according the method described by Melkko et al. (1990). By this method the intra-assay CV has been constantly around 37~ and the interassay CV close to 5% (Melkko et al. 1990). N-tact PTH IRMA kit utilized antibodies specific for PTH 39-84, bound to a solid phase, and PTH l-34 was labeled with 12’I. Simultaneous incubation with both of these antibodies was performed and, following the incubation period, each bead was washed to remove any unbound labeled antibody. The minimum detectable amount was 1.8 ngil with the intra-assay and interassay CV around 2%. The study protocol was approved by the Ethical Committee of the University Hospital, and every patient gave her informed consent. Repeated measures analyses of variance (ANOVA. Primer, McGraw-Hill, Inc.) were applied to the biochemical changes observed between the certain checkpoints.
Beclomethasone 200
1000
and inhaled beclomethasone
Results Significant decrease was noted between the prestudy mean serum morning osteocalcin (kg/l) and that after six and nine weeks of treatment with inhaled beclomethasone (200, 1000, and 2000 Fg. three weeks each). The decrease on 2000 p-g was from 4.4 to 3. I, p = 0.005, and began already on 1000 kg (3.6, p = 0.032. see Fig. 1). Increase was noticed in serum potassium (from 3.9 to 4.1 mmolll, p = 0.014, baseline vs 2000 pg), total calcium (Fig. 2), and ionised calcium values (Table I). A decreasing trend was noted in the plasma cortisol (baseline vs 2000 p,g: morning from 514 to 434 nmol/l, p = 0.080, and evening from 17 I to 109 nmol/l, p = 0.036). Twenty-four-hour urine excretion of free cortisol decreased throughout the study (from 153 to 77 nmol/l, p = 0.008). However, the plasma cortisol response to the tetracosactrin test was similar on the baseline and after beclomethasone at 2000 Kg/day (from 5 14 to 956 vs 434 to 844 nmolil). Other serum parameters investigated (e.g., blood
Beclomethasone 200
,
1000
clg I day , I
2000
pg I day 2000
3
3 Weeks
Fig. 1. Changes KI serum osteocalcin of nine asthmatIc patient5 after three successive periods of Inhaled beclomethasone (200. 1000. and 2000 pg/day. three weeks each).
6
9
Weeks Fig. 2. Serum total calcium values of nine asthmatic patients after three successive periods of inhaled beclomethasone (200, 1000, and 2000 &day. three weeks each).
H. Puolijoki et al.: Osteocalcin
and inhaled beclomethasone
287
Table I. Effect of inhaled beclomethasone postmenopausal
asthmatic
(200, 1000, and 2000 pg, three weeks each) on the serum characteristics women (ANOVA). N/A = not assessed
Characteristic
Baseline (SD)
Osteocalcin, pg/l Total calcium, mmol/l Ion&d calcium, mmol/l Alkaline phosphatase, U/l Alkaline phosphatase, bone originated,
PICP, kg/l PTH, rig/l Calcitonin, pmol/l D-25-OH-vitamin, nmol/l D-l ,25-OH-vitamin, pmol/l
DHEA, nmoU1 Estrone, pmol/l 17P-estradiol,
pmol/l
U/l
200 pglday
(SD)
1000 pg/day
(SD)
of calcium metabolism
2000 kg/day
(SD)
in nine
P
4.40 (1.89)
4.78 (1.29)
3.62 (1.47)
3.13 (1.25)
0.005
2.30 (0.08)
2.33 (0.06)
2.33 (0.08)
2.35 (0.08)
0.013
1.24 (0.04) 140 (34)
1.28 (0.04) 149 (38)
1.28 (0.06) 148 (39)
1.28 (0.03) 146 (41)
0.032 0.568
66 (23) 99 (25)
69 (26) 102 (25)
69 (33) 93 (30)
64 (30)
0.656
N/A N/A N/A N/A
N/A N/A N/A
96 21 6 62
(32) (5) (1) (16)
0.109 0.135 1.000 0.357
N/A
71 (15)
0.160
N/A
N/A N/A N/A
8.1 (4.3) 147 (43) 31 (25)
0.105 0.524 0.425
29 6 59 89
(14) (2) (13) (18)
12.0 (5.5) 164 (52) 47 (42)
haemoglobin or white cell count, serum sodium, phosphate, creatinine) did not differ significantly between the baseline and the end. The ratio of 24-hour urine excretion of calcium and creatinine did not vary significantly between the baseline and, for instance, on 2000 p,g beclomethasone/day (0.54 vs 0.42 mmol/mmol, p = 0.268, daily excretions of calcium 4.1 vs 3.5 mmol and those of creatine 7.6 vs 8.4 mmol, respectively). The results were similar in the 24-hour urine ratios for hydroxyprolinelcreatinine (9.7 vs 8.4 p,mol/mmol, p = 0.497, daily excretions of hydroxyproline 74 vs 70 kmol) and phosphate/creatinine (2.6 vs 2.8 mmoll mmol, p = 0.196, daily excretions of phosphate 19.8 vs 23.4 mmol). The total blood eosinophil count decreased in all patients (from 624 to 298 X lo’%, p = O.OOl), as did the daily use of sympatomimetic drugs. The symptoms of asthma decreased in all patients during the study course-+ven with beclomethasone at 200 p,g/day. Already this lowest dose caused statistically significant increases in the peak expiratory flow (PEF) and forced expiratory volume in one second (FEV,). Discussion The results show that high-dose inhaled beclomethasone has an effect on serum osteocalcin in postmenopausal asthmatic women. This agrees with the recent findings in healthy volunteers, both on inhaled (Hodsman et al. 1991, Pouw et al. 1991) and oral corticosteroid treatment (Hodsman et al. 1991, Nielsen et al. 1991). However, this preliminary study does not define the minimum dose and time needed for the change of serum osteocalcin, since every dosage had a carry-over effect. On the lowest dose 200 p,g beclomethasone/day increase in serum osteocalcin was detected in four patients. This might be due to the improvement in their asthmatic condition allowing, for example, increased mobilisation. Significant increase in serum total and ionised calcium was noted as a function of the inhaled corticosteroid dose, this also being in accordance with previous findings on oral corticosteroid treatment (LoCascio et al. 1990). This would appear to suggest increased bone resorption; however, the parameters measuring actual bone resorption did not change in the direction of excessive bone loss. Instead, the ratios of 24-hour urine calcium/ creatinine and hydroxyproline/creatinine showed a decreasing but not significant trend. Hydroxyproline, however, is a nonspecific marker and probably not sufficiently sensitive to pick up small changes within the normal range. Increased tubular reabsorption and increased calcium absorption are other possible causes for our finding, with the possible reduced activity of
N/A N/A
osteoblasts causing decreased influx of calcium from blood to these cells. In our patients, not even the use of high-dose inhaled beclomethasone evoked signs of secondary hyperparathyroidism as measured by changes in serum PTH, alkaline phosphatase, or bone-originated alkaline phosphatase, calcitonin, or vitamin D metabolites (Table I); probably a more prolonged period on corticosteroids and on higher doses than used in this study is necessary for the induction of secondary hyperparathyroidism (Fucik et al. 1975). Instead a decreasing but statistically insignificant trend was seen in serum PTH, this being in accordance with the increase of serum calcium. The significant decrease in 24-hour urine excretion of free cortisol reveals the suppressive action of high-dose inhaled beclomethasone on the pituitary-adrenal axis, even when the patients use a spacer and brush their mouths and throats carefully. Serum DHEA also showed a decreasing but statistically insignificant trend. In this study the low postmenopausal serum estrone and 17P-estradiol values did not change. The decrease in serum osteocalcin suggests a reduction in the osteoblast function on high-dose therapy. However, it is still uncertain if this finding really is connected to reduced function of osteoblasts or only to the reduced influx of osteocalcin from osteoblasts to the blood. The value of osteocalcin as a marker of bone matrix formation is unclear, because fluctuations in circulating osteocalcin may only reflect changes in the equilibrium between bone matrix and blood (Gundberg et al. 1991). The fact that neither serum PICP nor bone-originated alkaline phosphatase changed in our patients may refer to still intact bone formation. Further studies are needed to assess the effects of inhaled beclomethasone, both on the ability of the osteoblasts to form bone matrix and on the density of bone during a longer period of treatment with inhaled corticosteroid.
This study was supported Antituberculosis Association and the Turku are grateful to docent Juha Risteli, M.D., determination of serum PICP values, and Helsinki, for the determination of serum values.
Acknowledgment:
by grants from the Finnish University Foundation. We University of Oulu, for the to the Diacor Laboratories, e&one and 17e-estradiol
References British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Came, and National Asthma Campaign. Guidelines for
H. Puolijoki
288
management of asthma in adults: I--Chronic 301:651453; 1990.
persistent asthma. Br. Med. J.
Brown, I. P.; Delmas, P. D.; Malaval, L.; Edouard, C.; Chapuy , M. C. ; Meunier, P. I. Serum bone Gla-protein: A specific marker for bone formation in pastmenopausal osteoporosis. Lmcet i:lO9-1093; 1984. Fucik, R. F.; Kukreja, S. C.; Hargis. G.K.; Bower, E. N.; Henderson, W. J.; Williams, G. A. Effect of glucocorticoids on function of the parathyroid glands in man. .I. C&z. Endocrinol. Metab. 40~1052-1055; 1975. Gundberg, C. M.; Grant, F. D.; Conlin, P. R.; Chen, C. J.; Brown, E. M.: Johnson, P. I.; LeBoff, M. S. Acute changes in serum ostewalcin during induced hypocalcemia in humans. 1. Clin. Endocrinol. Metab. 72~438-443; 1991. Hodsman, A. B.; Toogood, I. H.; Jennings, B.; Fraher, L. J .; Baskervile, J. C. Differential effects of inhaled budesonide and oral prednisolone on serum osteocalcin. J. Clin. Emfocrinol. Metab. 72530-540; 1991. Irwin, W. S.; Barnes, E. W. Adrenocortical insufficiency. J. Clin. Endocrinol. Metab. 1:54%595; 1972. Lo Cascio, V.; Bonucci, E.; Imbimbo, B.; Ballanti, B .; Adami, S.; Milam, S .: Tartar&, D.; DellaRwca, C. Bone loss in response tu long term glucocorticoid therapy. Bone Min. 8:3%51; 1990.
et al.: Osteocalcin
and inhaled beclomethasone
Lukert, B.: Raisz, L. Glucocorticoid-induced osteoporosis: Pathogenesis and management. Ann. Intern. Med. 112~352-364, 1990. Melkko. J.; Niemi, S.; Risteli, L.; Risteli, I. Radioimmunoassay of the carboxyterminal propeptide of human type I procollagen. Clin. Chem. X132%1332; 1990. Nielsen, H. K.; Brixen, K.; Kassem, M.; Mosekilde, L. Acute effect of 1,25dihydmxyvitamin D,, prednisone and 1.25.dihydroxyvitamin D, plus prednisone on serum osteocalcin in normal individuals. J. Bone Min. Res. 6: 435-441; 1991. Pow. E. M.; Prummel, M. F.; Oosting, H.; CareI, M. R.; Endert, E. Beclomethasone inhalation decreases serum osteocalcin concentrations. Br. Med. J. 302:627428; 1991. Reed, P.; Holbrook, I. B.; McMurray, I. R.; Gardner, M. L. Hydroxyproline measurement in urine: A simple optimised method using HPLC. Am. Clin. B&hem. 25:Suppl. 169~170s; 1988.
August 28, 1991 December 2, 1991 Date Accepted: January 22, 1992 Date Received:
Date Revised:
Copyright
8756-3282192 $5.00 + .OO 0 1992 Pergamon Press Ltd.
Inhaled Beclomethasone Decreases Serum Osteocalcin in Postmenopausal Asthmatic Women H. PUOLIJOKI,’
K. LIIPPO,’
J. HERRALA,
J. SALM12
and E. TALA’
’ Department ofDiseases of the Chest. Turku University Central Hospital, SF-21540 Preitila, Finland * Departments of Medicine and 3Diseases of the Chest, Tampere University Hospital, SF-33520 Tampere, Finland Address for correspondence and reprints: H. Puolijoki, Department of Diseases of the Chest, Turku University Central Hospital,
SF-20520 Turku, Finland. Abstract
Materials and Methods
There are very few data as yet to quantify the effect of inhaled corticosteroids on bone metabolism, although the use of these drugs as a first-line treatment in bronchial asthma has widened. We determined the effect of three dose levels (200, 1000, 2000 &day, three weeks each) of inhaled beclomethasone on specific characteristics of bone metabolism in nine postmenopausal women with new asthma without any previous corticosteroid therapy. Significant decrease was noted in the mean serum morning osteocalcin concentration between the baseline and after nine weeks of beclomethasone (from 4.4 to 3.1 &I, p = 0.005). Significant increase in serum total and ionised calcium was found, although the parameters measuring bone resorption itself did not change. The results show that especially high-dose inhaled beclomethasone decreases serum osteocalcin in postmenopausal asthmatic women. Further studies are needed to assess the effects of inhaled beclomethasone, both on the ability of the osteoblasts to form bone matrix and on the density of bone during a longer treatment period on inhaled corticosteroids.
The study group comprised nine nonsmoking postmenopausal women (age range 54-66 years, mean 15 years postmenopausal) with newly diagnosed bronchial asthma. They had neither history of fractures nor any nutritional, metabolic, renal, or bone disease, and none had previously received inhaled or systemic corticosteroids for any indication; nor were they taking drugs affecting calcium or phosphate metabolism, and none had ever received estrogen or other hormone substitution. At every visit all patients were admitted to the in-patient ward. They were given thorough training in the use of inhaled drugs and the spacer, and were taught to brush the mouth and throat carefully after having administered the drug. All patients were allowed to use inhaled sympatomimetics to control their asthmatic symptoms. After two days of preparatory examinations, each patient started a low-collagen diet, which was continued to the sixth day. On the fifth day, 24-hour urine collection was started, and after the end of the collection on the sixth day at 7.30 a.m., study blood samples were taken, and the tetracosactrin test (Irwin & Barnes 1972) by SynactenR 250 pg performed (injected into muscle and serum cortisol measured before and after 60 minutes). However, the sample for serum evening cortisol value was taken at 7.30 p.m. on the fifth day. Each patient started beclomethasone (BecotideR metered dose inhaler) from the spacer (VolumaticR) as the sole corticosteroid throughout the study at a dose of 100 pg twice daily for three weeks, after which the patient was readmitted. She had already previously followed a low-collagen diet at home for two days. After 24-hour collection of urine, the blood samples and the ventilation examinations were taken. Thereafter, the beclomethasone dose was increased to 500 micrograms twice daily, and the measurements were repeated again after three weeks. In the final phase the patients took 1000 pg beclomethasone twice daily for three weeks, the recommended maximum daily dose (British Thoracic Society et al. 1990), and at the end the same measurements were repeated. Routine methods were used for the analysis of the usual blood values. Urine hydroxyproline was analysed using 4-chloro-7-nitrobenzofurazan as the derivisation reagent (Reed et al. 1988). Serum parathormone (PTH, Incstar), dehydroepiandrosterone (DHEA, Radioassay Systems Laboratories), estrone (Amersham), 17B-estradiol (Amersham), osteocalcin (Incstar), calcitonin (Amersham), and carboxyterminal propeptide of human type I procollagen (PICP, Farmos Diagnostica) values were mea-
Key Words: Asthma-Beclomethasone-Bone Inhaled corticosteroid-Osteocalcin-Osteoporosis.
gla-protein-
Introduction The effect of inhaled corticosteroids on bone metabolism is very important because of the widened use of these drugs as a firstline treatment in bronchial asthma. However, there are very few data as yet to quantify the risk of osteoporosis with inhaled corticosteroids, especially among postmenopausal women, who have an increased risk of osteoporosis on low-dose systemic corticosteroid therapy (Lukert & Raisz 1990). Pouw et al. (1991) noticed recently in healthy volunteers that high-dose inhaled beclomethasone decreases serum osteocalcin but does not affect its diurnal variation. Hodsman et al. (1991) found, also in healthy volunteers, that both oral prednisolone and inhaled budesonide induced dose-dependent reductions in serum osteocalcin. In response to calcitriol, serum osteocalcin increased in the budesonide-treated healthy subjects, but not among those administered prednisolone. We studied specific characteristics of calcium metabolism for three successive periods with three different dosages of inhaled beclomethasone among postmenopausal asthmatic women.
H. Fuolijoki et al.: Osteocalcin
286
(RIA) or immunoradiometric sured later by radioimmunoassay assay (IRMA) from the samples frozen to - 70” C immediately. The lncstar Osteocalcin RIA employed simultaneous addition of sample, rabbit antibovine osteocalcin antibody and “‘1 bovine osteocalcin, followed by an overnight incubation at 2”-8” C. Phase separation was accomplished by the addition of a complex of goat anti-rabbit serum and polyethylene glycol. The assay was centrifuged and decanted after a two-hour incubation at 2”-8” C. The minimum detectable amount was determined to be 0.2 p.gil. lntra-assay and interassay variations (CV) were determined to be around 2%. The radioimmunoassay of PICP was performed by docent Juha Risteli, according the method described by Melkko et al. (1990). By this method the intra-assay CV has been constantly around 37~ and the interassay CV close to 5% (Melkko et al. 1990). N-tact PTH IRMA kit utilized antibodies specific for PTH 39-84, bound to a solid phase, and PTH l-34 was labeled with 12’I. Simultaneous incubation with both of these antibodies was performed and, following the incubation period, each bead was washed to remove any unbound labeled antibody. The minimum detectable amount was 1.8 ngil with the intra-assay and interassay CV around 2%. The study protocol was approved by the Ethical Committee of the University Hospital, and every patient gave her informed consent. Repeated measures analyses of variance (ANOVA. Primer, McGraw-Hill, Inc.) were applied to the biochemical changes observed between the certain checkpoints.
Beclomethasone 200
1000
and inhaled beclomethasone
Results Significant decrease was noted between the prestudy mean serum morning osteocalcin (kg/l) and that after six and nine weeks of treatment with inhaled beclomethasone (200, 1000, and 2000 Fg. three weeks each). The decrease on 2000 p-g was from 4.4 to 3. I, p = 0.005, and began already on 1000 kg (3.6, p = 0.032. see Fig. 1). Increase was noticed in serum potassium (from 3.9 to 4.1 mmolll, p = 0.014, baseline vs 2000 pg), total calcium (Fig. 2), and ionised calcium values (Table I). A decreasing trend was noted in the plasma cortisol (baseline vs 2000 p,g: morning from 514 to 434 nmol/l, p = 0.080, and evening from 17 I to 109 nmol/l, p = 0.036). Twenty-four-hour urine excretion of free cortisol decreased throughout the study (from 153 to 77 nmol/l, p = 0.008). However, the plasma cortisol response to the tetracosactrin test was similar on the baseline and after beclomethasone at 2000 Kg/day (from 5 14 to 956 vs 434 to 844 nmolil). Other serum parameters investigated (e.g., blood
Beclomethasone 200
,
1000
clg I day , I
2000
pg I day 2000
3
3 Weeks
Fig. 1. Changes KI serum osteocalcin of nine asthmatIc patient5 after three successive periods of Inhaled beclomethasone (200. 1000. and 2000 pg/day. three weeks each).
6
9
Weeks Fig. 2. Serum total calcium values of nine asthmatic patients after three successive periods of inhaled beclomethasone (200, 1000, and 2000 &day. three weeks each).
H. Puolijoki et al.: Osteocalcin
and inhaled beclomethasone
287
Table I. Effect of inhaled beclomethasone postmenopausal
asthmatic
(200, 1000, and 2000 pg, three weeks each) on the serum characteristics women (ANOVA). N/A = not assessed
Characteristic
Baseline (SD)
Osteocalcin, pg/l Total calcium, mmol/l Ion&d calcium, mmol/l Alkaline phosphatase, U/l Alkaline phosphatase, bone originated,
PICP, kg/l PTH, rig/l Calcitonin, pmol/l D-25-OH-vitamin, nmol/l D-l ,25-OH-vitamin, pmol/l
DHEA, nmoU1 Estrone, pmol/l 17P-estradiol,
pmol/l
U/l
200 pglday
(SD)
1000 pg/day
(SD)
of calcium metabolism
2000 kg/day
(SD)
in nine
P
4.40 (1.89)
4.78 (1.29)
3.62 (1.47)
3.13 (1.25)
0.005
2.30 (0.08)
2.33 (0.06)
2.33 (0.08)
2.35 (0.08)
0.013
1.24 (0.04) 140 (34)
1.28 (0.04) 149 (38)
1.28 (0.06) 148 (39)
1.28 (0.03) 146 (41)
0.032 0.568
66 (23) 99 (25)
69 (26) 102 (25)
69 (33) 93 (30)
64 (30)
0.656
N/A N/A N/A N/A
N/A N/A N/A
96 21 6 62
(32) (5) (1) (16)
0.109 0.135 1.000 0.357
N/A
71 (15)
0.160
N/A
N/A N/A N/A
8.1 (4.3) 147 (43) 31 (25)
0.105 0.524 0.425
29 6 59 89
(14) (2) (13) (18)
12.0 (5.5) 164 (52) 47 (42)
haemoglobin or white cell count, serum sodium, phosphate, creatinine) did not differ significantly between the baseline and the end. The ratio of 24-hour urine excretion of calcium and creatinine did not vary significantly between the baseline and, for instance, on 2000 p,g beclomethasone/day (0.54 vs 0.42 mmol/mmol, p = 0.268, daily excretions of calcium 4.1 vs 3.5 mmol and those of creatine 7.6 vs 8.4 mmol, respectively). The results were similar in the 24-hour urine ratios for hydroxyprolinelcreatinine (9.7 vs 8.4 p,mol/mmol, p = 0.497, daily excretions of hydroxyproline 74 vs 70 kmol) and phosphate/creatinine (2.6 vs 2.8 mmoll mmol, p = 0.196, daily excretions of phosphate 19.8 vs 23.4 mmol). The total blood eosinophil count decreased in all patients (from 624 to 298 X lo’%, p = O.OOl), as did the daily use of sympatomimetic drugs. The symptoms of asthma decreased in all patients during the study course-+ven with beclomethasone at 200 p,g/day. Already this lowest dose caused statistically significant increases in the peak expiratory flow (PEF) and forced expiratory volume in one second (FEV,). Discussion The results show that high-dose inhaled beclomethasone has an effect on serum osteocalcin in postmenopausal asthmatic women. This agrees with the recent findings in healthy volunteers, both on inhaled (Hodsman et al. 1991, Pouw et al. 1991) and oral corticosteroid treatment (Hodsman et al. 1991, Nielsen et al. 1991). However, this preliminary study does not define the minimum dose and time needed for the change of serum osteocalcin, since every dosage had a carry-over effect. On the lowest dose 200 p,g beclomethasone/day increase in serum osteocalcin was detected in four patients. This might be due to the improvement in their asthmatic condition allowing, for example, increased mobilisation. Significant increase in serum total and ionised calcium was noted as a function of the inhaled corticosteroid dose, this also being in accordance with previous findings on oral corticosteroid treatment (LoCascio et al. 1990). This would appear to suggest increased bone resorption; however, the parameters measuring actual bone resorption did not change in the direction of excessive bone loss. Instead, the ratios of 24-hour urine calcium/ creatinine and hydroxyproline/creatinine showed a decreasing but not significant trend. Hydroxyproline, however, is a nonspecific marker and probably not sufficiently sensitive to pick up small changes within the normal range. Increased tubular reabsorption and increased calcium absorption are other possible causes for our finding, with the possible reduced activity of
N/A N/A
osteoblasts causing decreased influx of calcium from blood to these cells. In our patients, not even the use of high-dose inhaled beclomethasone evoked signs of secondary hyperparathyroidism as measured by changes in serum PTH, alkaline phosphatase, or bone-originated alkaline phosphatase, calcitonin, or vitamin D metabolites (Table I); probably a more prolonged period on corticosteroids and on higher doses than used in this study is necessary for the induction of secondary hyperparathyroidism (Fucik et al. 1975). Instead a decreasing but statistically insignificant trend was seen in serum PTH, this being in accordance with the increase of serum calcium. The significant decrease in 24-hour urine excretion of free cortisol reveals the suppressive action of high-dose inhaled beclomethasone on the pituitary-adrenal axis, even when the patients use a spacer and brush their mouths and throats carefully. Serum DHEA also showed a decreasing but statistically insignificant trend. In this study the low postmenopausal serum estrone and 17P-estradiol values did not change. The decrease in serum osteocalcin suggests a reduction in the osteoblast function on high-dose therapy. However, it is still uncertain if this finding really is connected to reduced function of osteoblasts or only to the reduced influx of osteocalcin from osteoblasts to the blood. The value of osteocalcin as a marker of bone matrix formation is unclear, because fluctuations in circulating osteocalcin may only reflect changes in the equilibrium between bone matrix and blood (Gundberg et al. 1991). The fact that neither serum PICP nor bone-originated alkaline phosphatase changed in our patients may refer to still intact bone formation. Further studies are needed to assess the effects of inhaled beclomethasone, both on the ability of the osteoblasts to form bone matrix and on the density of bone during a longer period of treatment with inhaled corticosteroid.
This study was supported Antituberculosis Association and the Turku are grateful to docent Juha Risteli, M.D., determination of serum PICP values, and Helsinki, for the determination of serum values.
Acknowledgment:
by grants from the Finnish University Foundation. We University of Oulu, for the to the Diacor Laboratories, e&one and 17e-estradiol
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August 28, 1991 December 2, 1991 Date Accepted: January 22, 1992 Date Received:
Date Revised:
