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Given the published evidence, ICSs should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations. However, caution must be taken with doses greater than 1000 µg/d (chlorofluorocarbon beclomethasone equivalent), although whether such doses cause adverse effects is currently still questionable. Patient education on proper ICS administration and adherence, including during the first trimester, must be ongoing. Well controlled asthma will reduce the need for higher ICS doses and possible exposure to systemic corticosteroids, and might decrease the risk of adverse pregnancy or perinatal outcomes.

Osteoporosis is particularly common in smokers, postmenopausal women, the elderly, underweight or immobile, and patients with diabetes or lung problems. Osteoporosis may result in fractures of the spine, ribs or hip joint with minimal trauma. These occur after the first year in 10–20% of patients treated with more than mg prednisone daily. It is estimated that up to 50% of patients on long-term prednisone will develop bone fractures. Vertebral fractures are more common in patients on steroids, even in those with normal bone density.

Because of these side effects, doctors frequently choose safer medications, such as the 5-ASA drugs and antibiotics, as initial therapy. But there are a number of ways to reduce the risk of developing side effects. These include rapid but careful tapering off of steroids; alternate-day dosing; rectally applied corticosteroids; and rapidly metabolized corticosteroids such as budesonide (described above). To help prevent osteoporosis, many doctors routinely prescribe calcium supplements as well as multivitamins that contain vitamin D. Another option is the use of bisphosphonates, such as risedronate (Actonel®) and alendronate (Fosamax®). These compounds, which have been shown to help avert bone loss, are effective in treating and preventing steroid-induced osteoporosis.

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