We may wish to conveniently conclude that inhaled corticosteroid (ICS) use does not cause thinning of the bone. However, it is more appropriate to think about the complexity of the situation. The administration of systemic corticosteroids (SCSs) at a larger than minimum dose, and particularly if they are administered over a long period of time, is generally thought to cause osteopenia and osteoporosis.2 Whether ICS therapy produces adequate blood levels that can adversely affect BMD is not certain, but even a small effect over an extended period of time may produce serious side effects. In terms of benefits, ICSs have been shown to reduce the frequency of acute exacerbations in patients with moderate-to-severe COPD, and this would benefit the individual by reducing the use of SCSs for rescue.5 ICS therapy has been shown to improve the quality of life of the individual,5 and this would add to the mobility and physical activities of the individual. Finally, COPD lungs are a source of proinflammatory molecules and a contributor to systemic inflammation. If ICS therapy can reduce the lung source of these molecules, it may actually be beneficial to the bones.6 This current trial is complicated by a multitude of confounding factors, such as prior and concurrent use of powerful BMD medications, the use of ICSs and SCSs, smoking practice, and differences in the nutrition and physical activity levels of the individuals. The high prevalence of osteoporosis and osteopenia in this population and, more importantly, the small sample size, due to a dropout rate of > 50% in the clinical trial, do not help to provide a simple conclusion. Moreover, more women in the FP-based arms of the trial began to receive a BMD-sparing drug during follow-up than those in the placebo arm (34% vs 19%, respectively; relative risk, 1.79; p = 0.03), which further complicates the BMD data. Predictably, it would be very hard to tease out the medication effect of ICS therapy. On the basis of the evidence presented, while this trial has added to the body of literature, it has not resolved the controversy of whether or not ICS therapy aggravates or causes osteoporosis.