Osteoporosis in patients with inflammatory bowel disease

Effect of hip flexion on the measurement of spinal bone mineral density in the Norland Eclipse XR

It is recommended that the hip joints be flexed to 90 degrees during dual-energy X-ray absorptiometry scanning of the lumbar spine in the anteroposterior projection; however, some patients are unable to maintain this position because of the presence of degenerative changes in lower limb joints. This study examines the effect of a lesser degree of hip flexion on the lumbar spine bone mineral density (BMD) measurement and its interpretation. Fifty women were scanned on the Norland Eclipse XR, initially in the standard position with the hips flexed to 90 degrees and then in the adjusted position after allowing for some degree of hip extension to keep them comfortable (hip flexion of 60 degrees -70 degrees ). Higher bone mineral content (BMC), surface area, and BMD values were seen in the standard position compared to the adjusted position, but none of the differences was statistically significant. There were strong correlations for BMC,surface area, and BMD measured in the two positions. In the standard position, 26 women were found to have osteoporosis and 18 had osteopenia. In the adjusted position, osteoporosis was noted in 27 women, and 18 had osteopenia. Four women showed a reduction, whereas 12 women showed an increase in BMD in excess of the least significant change at the 95% confidence level, defined as 2.77 times the precision error (0.008 g/cm(2) x 2.77 = 0.120 g/cm(2)). Our study demonstrates that a lesser degree of hip flexion in women who find it difficult to maintain the recommended 90 degrees hip flexion during the lumbar spine BMD measurement would not affect the patient classification based on T-scores recommended by the World Health Organization; however, variation in hip flexion can be a major confounding factor when interpreting a change in BMD over time.

Vitamin supplementation: what the gastroenterologist needs to know

BACKGROUND

The vitamin business is a multimillion dollar industry. Aggressive marketing strategies are used to make claims for the health benefits of these products. Observational studies suggest that people who consume vitamin supplements decrease their risks for cancer, cardiovascular disease, and gastrointestinal disease. What is the evidence for these claims, and as a prescribing gastroenterologist, is there a scientific basis for vitamin supplementation?

METHODS

A narrative review focusing on randomized controlled trials, where available, plus observational studies obtained from personal files, "on-line" searches, and references in reviewed articles.

RESULTS

From the perspective of a gastroenterologist, there is strong evidence to recommend B12 supplementation in gastric and intestinal disease, as well as pernicious anemia. There exists moderate evidence to support B12 supplements in pancreatic disease. Vitamin D and calcium supplementation are recommended for persons with disorders of malabsorption, cholestasis, and illnesses requiring chronic steroids. Only observational studies suggest a correlation between vitamin D/calcium and decreased colorectal adenoma recurrence. Although folic acid supplementation is beneficial in persons on medications such as methotrexate and sulfasalazine, studies are contradictory with regard to folic acid and colon cancer prevention. Overall, antioxidants have not been proven to decrease the risk for colorectal adenoma, gastric cancer, or esophageal cancer.

CONCLUSIONS

Observational studies do not correlate with randomized clinical trials; therefore, few definitive recommendations can be made. Vitamin supplements are appropriate for recognized deficiencies; however, there is a lack of evidence to support their effects in the prevention of chronic disease.

Rapid hip bone loss in active Crohn's disease patients receiving short-term corticosteroid therapy

BACKGROUND

Uncertainty over whether corticosteroids cause bone loss in patients with Crohn's disease may reflect their short, intermittent use.

AIM

We investigated whether a 2-month course of prednisolone is associated with detectable bone loss.

METHODS

Fifteen patients with active Crohn's disease and 19 controls with inactive Crohn's disease were recruited. Bone mineral density of the lumbar spine and hip was measured at baseline and 2 and 8 months.

RESULTS

At 2 months, significant bone loss was found in patients with active disease (femoral neck -2.7%, P < 0.002; Ward's triangle -3.9%, P < 0.01). Although bone mineral density was still lower at 8 months, these differences were no longer significant (-1.3% and -3.4%, femoral neck and Ward's triangle, respectively). No significant change in hip bone mineral density was observed in controls. Previous corticosteroid use was not significantly associated with baseline bone mineral density, although significant independent associations were observed between weight, site of disease and lumbar spine bone mineral density, and between dietary calcium deficiency and femoral neck and Ward's triangle bone mineral density.

CONCLUSION

Significant bone loss at the hip can be detected in patients receiving corticosteroid treatment for 2 months for active Crohn's disease ; however, it remains unclear whether this is because of disease activity or its treatment. This rapid bone loss may represent a risk factor for fracture and justify bone protective therapy.

The short-term effects of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) on bone formation and bone mineral density in acute ulcerative colitis

BACKGROUND

The aetiology of bone loss in ulcerative colitis is multifactorial, but corticosteroid treatment is an important risk factor. A novel formulation of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) has been developed, in order to deliver high mucosal levels of prednisolone within the colon but with little systemic absorption. The aim of this study was to investigate its efficacy, and short-term effects on bone formation and bone mineral density.

METHODS

In a 12-week longitudinal study 13 patients with active colitis were treated with a reducing dose of Predocol. Disease activity scores were recorded and the bone formation marker osteocalcin was measured before, during and after treatment, with hip and spine bone mineral density assessed at baseline and after treatment.

RESULTS

Eleven of the 13 patients completed the study. Compared with baseline, disease activity scores improved significantly after 4 weeks [difference in means, 6.9; 95% confidence interval (CI), 5.2, 8.7; P < 0.0001] and 12 weeks (difference in means, 5.7; 95% CI, 3.3, 8.2; P < 0.0001) of treatment. Osteocalcin did not fall compared with baseline [16.91 mg/l (95% CI, 12.70, 21.12)], after 4 weeks [13.67 mg/l (95% CI, 8.72, 18.60)] (difference in means, 3.25; 95% CI, 2.37, 8.87; P = 0.23) or 12 weeks [23.91 mg/l (95% CI, 16.10, 31.74)] (difference in means, 13.23; 95% CI, 2.45, 16.48; P = 0.13) of treatment. Similarly, bone mineral density at the hip [0.99 g/cm (95% CI, 0.90, 1.09)] did not change after 12 weeks of treatment [1.00 g/cm (95% CI, 0.89, 1.11)] (difference in means, 0.01; 95% CI, 0.25, 0.34; P = 0.74). Spine bone mineral density did not fall from pre-treatment levels [1.20 g/cm (95% CI, 1.11, 1.30)] after 12 weeks [1.19 g/cm (95% CI, 1.10, 1.29)] (difference in means, 0.01; 95% CI, 0.004, 0.01; P = 0.26).

CONCLUSIONS

These results confirm that Predocol is effective treatment for acute ulcerative colitis and short courses of the steroid have no adverse effects on bone formation and bone mineral density. The encouraging results from this study suggest that Predocol may be a significant advance in preventing corticosteroid induced bone loss in ulcerative colitis.

Interleukin 10-deficient mice develop osteopenia, decreased bone formation, and mechanical fragility of long bones

BACKGROUND & AIMS

Bone loss is a common complication of human inflammatory bowel disease (IBD), but its mechanisms are not understood completely. We investigated bone metabolism in interleukin-10-deficient ( IL-10-/- ) mice, an animal model with IBD features.

METHODS

IL-10-/- male mice (8- and 12-weeks-old) and their age-matched wild-type counterparts (C57BL/6J) were studied. Bone mass of the femur was determined by ashing. Tibial cancellous and cortical bone mass and formation was measured by static and dynamic histomorphometry. Biomechanical strength of the femur was tested. Primary bone marrow stromal cell cultures were used to assess osteoblast generation. Serum levels of 25-OH vitamin D 3, insulin-like growth factor-1 (IGF-1), parathyroid hormone, osteocalcin, and deoxy-pyridinoline cross-links were measured. The presence of colitis was determined histologically, and by IL-12 and interferon-gamma (IFN-gamma) secretion from cultured colonic explants.

RESULTS

Eight- and 12-week-old IL-10-/- mice developed osteopenia of both cancellous and cortical bone, evidenced by lower femoral ash weight, cancellous bone area and surface, trabecular number, and decreased cortical bone area and width. Osteopenia was associated with mechanical fragility, manifested by decreased stiffness and mechanical load at fracture, and was caused by suppressed bone formation, indicated by decreased cancellous double-labeled surface, mineralizing surface, serum osteocalcin level, and mineralized nodule number in bone marrow stromal cell cultures. IL-10-/- mice with colitis had significantly less bone mass compared with IL-10-/- mice without colitis.

CONCLUSIONS

IL-10-/- mice develop the hallmarks of osteoporosis, that is, reduced bone mass, increased mechanical fragility, and suppressed bone formation. The presence of colitis is an important contributor to osteoporosis in IL-10-/- mice.

Measurement of vitamin D levels in inflammatory bowel disease patients reveals a subset of Crohn's disease patients with elevated 1,25-dihydroxyvitamin D and low bone mineral density

OBJECTIVES

Many patients with Crohn's disease (CD) have low bone mineral density (BMD) that may not be solely attributable to glucocorticoid use. We hypothesised that low BMD in patients with CD is associated with elevated circulating levels of the active form of vitamin D, 1,25-dihydroxyvitamin D (1,25(OH)(2)D). We further hypothesised that this was secondary to increased synthesis of 1,25(OH)(2)D by inflammatory cells in the intestine. The aim of this study was to examine the relationship between 1,25(OH)(2)D levels and BMD in patients with CD.

METHODS

An IRB approved retrospective review of medical records from patients with CD (n = 138) or ulcerative colitis (UC, n = 29). Measurements of vitamin D metabolites and immunoreactive parathyroid hormone (iPTH) were carried out. BMD results were available for 88 CD and 20 UC patients. Immunohistochemistry or real time reverse transcription-polymerase chain reaction (RT-PCR) for the enzyme 1alpha-hydroxylase was performed on colonic biopsies from patients with CD (14) or UC (12) and normal colons (4).

RESULTS

Inappropriately high levels of serum 1,25(OH)(2)D (>60 pg/ml) were observed in 42% of patients with CD compared with only 7% in UC, despite no differences in mean iPTH. Serum 1,25(OH)(2)D levels were higher in CD (57 pg/ml) versus UC (41 pg/ml) (p = 0.0001). In patients with CD, there was a negative correlation between 1,25(OH)(2)D levels and lumbar BMD (r = -0.301, p = 0.005) independent of therapeutic glucocorticoid use. 1,25(OH)(2)D levels also correlated with CD activity. Lastly, immunohistochemistry and RT-PCR demonstrated increased expression of intestinal 1alpha-hydroxylase in patients with CD.

CONCLUSIONS

These data demonstrate that elevated 1,25(OH)(2)D is more common in CD than previously appreciated and is independently associated with low bone mineral density. The source of the active vitamin D may be the inflamed intestine. Treatment of the underlying inflammation may improve metabolic bone disease in this subgroup of patients.

Bones and Crohn's: risk factors associated with low bone mineral density in patients with Crohn's disease

Previous studies have confirmed that the prevalence of decreased bone mineral density is elevated in patients with inflammatory bowel disease. The objective of the current study was to determine the prevalence of osteopenia and osteoporosis in a cross-sectional outpatient population of 242 adult patients with Crohn's disease and to determine which clinical characteristics and serum and urine biochemical factors might be predictive of bone loss. Thirty-seven percent had normal bone density, 50.0% were osteopenic, and 12.9% were osteoporotic. Among the sites used to diagnose low bone mineral density, the femoral neck demonstrated the highest prevalence of osteopenia and the ultra-distal radius the highest prevalence of osteoporosis. However, low bone mineral density at one site was always predictive of low bone mineral density at the other. Corticosteroid use during the year before assessment was found to be consistently predictive of low bone mineral density in males but not in females. In contrast, low body mass index and high platelet counts were consistently predictive of low bone mineral density in females but not in males. Disease location, smoking, and age were not predictive of changes in bone mineral density.

Hip fractures in patients with inflammatory bowel disease and their relationship to corticosteroid use: a population based cohort study

BACKGROUND

Inflammatory bowel disease (IBD) is known to be associated with reduced bone density but the extent to which this results in an increased risk of fracture and the contribution of corticosteroid therapy are unclear. We have conducted a large cohort study to address these issues.

METHODS

We selected subjects within the General Practice Research Database (GPRD) with a diagnosis of IBD and up to five matched controls for each patient. We derived dates of recorded hip fractures and also information on smoking, use of corticosteroids, and a number of other drugs. We calculated the absolute risk of fracture and the relative risk as a hazard ratio corrected for available confounders by Cox regression.

RESULTS

Seventy two hip fractures were recorded in 16 550 IBD cases and 223 in 82 917 controls. Cox modelling gave an unadjusted relative risk of hip fracture of 1.62 (95% confidence interval (CI) 1.24-2.11) for all IBD, 1.49 (1.04-2.15) for ulcerative colitis (UC) and 2.08 (1.36-3.18) for Crohn's disease (CD). Multivariate modelling showed that both current and cumulative use of corticosteroids and use of opioid analgesics confounded this relationship. After adjusting for confounding, the relative risk was 1.41 (0.94-2.11) for UC and 1.68 (1.01-2.78) for CD.

CONCLUSION

The risk of hip fracture is increased approximately 60% in IBD patients. Corticosteroid use is a contributor to this, both in the long term as previously recognised and also in an acute reversible manner. The majority of hip fracture risk in IBD patients however cannot be attributed to steroid use.

Bone density improves with disease remission in patients with inflammatory bowel disease

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) are at risk of low bone mineral density (BMD). The aim of this cross-sectional study was to investigate (i) whether patients with IBD in long-term remission have greater bone density relative to patients with active disease, (ii) the effect of remission on BMD in ulcerative colitis and Crohn's disease, and (iii) the effect of azathioprine treatment, used to induce remission, on BMD.

PATIENTS AND METHODS

BMD relative to the age-standardised mean (Z-score) was measured by dual-energy X-ray absorptiometry at the left femoral neck and lumbar spine in consecutive patients with IBD. Patients were divided into the following groups: (i) active disease, (ii) remission of less than one year, (iii) remission of one to three years, and (iv) remission of more than three years. Active disease was defined as three or more bowel motions per day, treatment with oral or rectal corticosteroids, and/or presence of a fistula. The subgroups with ulcerative colitis and Crohn's disease and the effect of taking azathioprine were compared. All results were controlled for confounding variables. RESULTS A total of 137 (64 ulcerative colitis, 73 Crohn's disease) patients were evaluated. Patients in remission for more than three years had a normal mean Z-score that was significantly higher than those with active disease at both the femoral neck and the lumbar spine for both ulcerative colitis and Crohn's disease. Patients taking azathioprine and in remission had significantly higher mean Z-scores at the lumbar spine than patients with active disease and who were not taking azathioprine.

CONCLUSION

In patients with ulcerative colitis and Crohn's disease, age-matched BMD is higher with increasing duration of disease remission and induction of remission by azathioprine.

A randomized controlled trial of calcium with vitamin D, alone or in combination with intravenous pamidronate, for the treatment of low bone mineral density associated with Crohn's disease

BACKGROUND

Osteoporosis is a common complication of Crohn's disease.

AIM

To study the effect on the bone mineral density of a bisphosphonate (pamidronate) given intravenously, in combination with oral calcium and vitamin D supplements, compared with oral calcium and vitamin D supplements alone.

METHODS

Seventy-four patients with Crohn's disease and low bone mineral density at the lumbar spine and/or hip were randomized to receive either a daily dose of 500 mg of calcium with 400 IU of vitamin D alone or in combination with four three-monthly infusions of 30 mg of intravenous pamidronate over the course of 12 months. The main outcome measure was the change in bone mineral density at the lumbar spine and hip, measured by dual X-ray absorptiometry, at baseline and 12 months.

RESULTS

Both groups gained bone mineral density at the lumbar spine and hip after 12 months. There were significant (P < 0.05) changes in the pamidronate group, with gains of + 2.6%[95% confidence interval (CI), 1.4-3.0] at the spine and + 1.6% (95% CI, 0.6-2.5) at the hip, compared with gains of + 1.6% (95% CI, - 0.1-3.2) and + 0.9% (95% CI, - 0.4-2.1) at the spine and hip, respectively, in the group taking vitamin D and calcium supplements alone.

CONCLUSIONS

In patients with Crohn's disease and low bone mineral density, intravenous pamidronate significantly increases the bone mineral density at the lumbar spine and hip.

Inflammatory bowel disease and the risk of fracture

BACKGROUND & AIMS

Although patients with inflammatory bowel disease (IBD) have reduced bone mass, there is controversy whether there is an increased risk of fracture. This study examines the risk of fracture and its predictors in patients with IBD.

METHODS

In a primary care- based nested case-control study, 231,778 fracture cases and 231,778 age- and sex-matched controls were recruited. A history of IBD was assessed from medical records.

RESULTS

The prevalence of IBD was 156 and 282 per 100,000 for Crohn's disease (CD) and ulcerative colitis (UC), respectively. Patients with IBD had an increased risk of vertebral fracture (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.61) and hip fracture (OR, 1.59; 95% CI, 1.14-2.23). The risk of hip fracture was greater in patients with CD (OR, 1.86; 95% CI, 1.08-3.21) compared with UC (OR, 1.40; 95% CI, 0.92-2.13). Disease severity, assessed by the number of symptoms, predicted fracture even after adjusting for corticosteroid use (OR, 1.46; 95% CI, 1.04-2.04). Only 13% of patients with IBD who had already sustained a fracture were on any form of antifracture treatment.

CONCLUSIONS

Patients with IBD have a higher risk of fracture due to both disease activity and use of oral corticosteroids. However, few of these patients are receiving optimal bone-sparing therapy, highlighting the importance of increasing awareness of osteoporosis in those managing these patients.

Risk of fracture in ulcerative colitis: a population-based study from Olmsted County, Minnesota

BACKGROUND & AIMS

Osteopenia is common in patients with ulcerative colitis (UC), but less is known about fracture risk. Previously we were unable to demonstrate increased fractures in a population-based cohort with Crohn's disease.

METHODS

Medical records of 273 Olmsted County, Minnesota residents initially diagnosed with UC in 1940-1993 were reviewed for evidence of subsequent fractures, as were records of a control cohort of county residents matched on age and gender. Cumulative fracture incidence after diagnosis was estimated by using the Kaplan-Meier method. The hazard ratio of fracture in cases relative to control subjects was estimated by Cox proportional hazards regression, which was also used to evaluate potential risk factors for fracture.

RESULTS

Median follow-up was 13 years (range, 1 day-53 years). The cumulative incidence of any fracture from time of diagnosis was 40% at 25 years versus 42% in control subjects (P=0.615). The hazard ratio in cases compared to control subjects was 1.1 (95% confidence interval, 0.8-1.6) for any fracture and 1.3 (95% confidence interval, 0.6-2.8) for any osteoporotic fracture (hip, spine, or wrist as a result of moderate trauma). Other causes of secondary osteoporosis were associated with increased fracture risk, whereas estrogen use was protective. One hundred three cases received any corticosteroids (38%), and 34 (12%) had taken corticosteroids for 6 months or longer. Corticosteroids and bowel resection were not associated with fracture risk.

CONCLUSIONS

In this population-based cohort of patients with UC, fracture risk was not elevated relative to matched community control subjects. Use of corticosteroids did not appear to significantly influence the risk of fracture.

Bone loss associated with gastrointestinal disease: prevalence and pathogenesis

Decreased bone mineral density is a frequent finding in gastrointestinal disease. Factors contributing to this are (1) malabsorption of vitamin D, calcium and possibly vitamin K and other nutrients; (2) treatment with glucocorticoids; (3) inflammatory cytokines in inflammatory bowel disease; and (4) hypogonadism induced by gastrointestinal disease. A low bone mineral density has been reported in (1) patients who have undergone gastrectomy (27-44% with Z-scores of < -1); (2) pernicious anaemia; (3) coeliac disease (8-22% with Z-scores of < -2); (4) Crohn's disease (mean 32-38% with Z-scores of < -1); and (5) ulcerative colitis (mean 23-25% with Z-scores of < -1). Reduced bone mineral density is thus prevalent in these individuals and is compounded by age related bone loss, leading to the development of severe bone disease in some patients.

The association between corticosteroid use and development of fractures among IBD patients in a population-based database

OBJECTIVES

Because the rate of fracture among patients with inflammatory bowel disease (IBD) is only slightly higher than that in the general population, it is important to define high-risk groups worthy of diagnostic evaluation or prophylactic interventions. Corticosteroid use has been considered in other diseases to be a risk for fracture, although not all studies in IBD are concordant on this point. We aimed to determine whether patients with IBD drawn from a population-based database who sustain fractures are more likely to have been using corticosteroids than a matched group of IBD patients who did not fracture.

METHODS

We extracted from our population-based University of Manitoba Inflammatory Bowel Disease Epidemiology Database the number of patients with a new diagnosis of fracture between the years 1997-2000. From within our Inflammatory Bowel Disease Epidemiology Database, we extracted a control group of IBD patients who did not develop fractures matched to the case group who did by age, gender, diagnosis, year of diagnosis, and geographic area of residence. We linked our cohorts with Manitoba Health's Drug Program Information Network to study corticosteroid use within 2 yr before fracture diagnosis. The Drug Program Information Network is a population-based database, established in 1995, which records all prescription drugs.

RESULTS

Fractures were identified in 13 patients with Crohn's disease and in 28 patients with ulcerative colitis. The control group included 103 Crohn's disease and 173 ulcerative colitis patients who did not fracture. In Crohn's disease, for the group who fractured compared with the controls who did not fracture, corticosteroid use before fracture was evident in seven (54%) compared with 21 (22%) who did not fracture (chi(2) = 4.45, df = 1, p = 0.035). In ulcerative colitis, for the group who fractured compared with the controls who did not fracture, corticosteroid use before fracture was evident in five (18%) compared with 37 (21%) who did not fracture (chi(2) = 0.031, df = 1, p = 0.861). Fracture cases were more likely to be exposed to oral corticosteroids (OR = 1.75; 95% CI = 0.82-3.75), but this result is not significant. Regarding corticosteroid dosing among the 12 patients with IBD who fractured and used corticosteroids, the mean total days supply was 314 days +/- 236 days compared with 258 days +/- 278 days in those who did not fracture (p = 0.16). The prescribed daily dose among corticosteroid users was comparable for those who fractured versus those who did not fracture (18 mg/day vs 21 mg/day, p = 0.90).

CONCLUSIONS

Patients who require corticosteroids in Crohn's disease should be considered at risk for fracture. Further research is required to delineate after how much corticosteroid use are subjects at risk and/or after what duration of active disease.

Assessment of the risk of fracture in patients with gastrointestinal disease

Osteoporotic fractures are a common problem and associated with significant morbidity, mortality and costs. There is now increasing evidence that patients with coeliac disease are at an increased risk of osteoporotic fracture. With the advent of new therapeutic agents to reduce the risk of fracture, it is important to identify people at highest risk. The best predictors of future fracture include a previous osteoporotic fracture, low bone density, active inflammatory bowel disease, the use of oral corticosteroids and an increased risk of falling.

The pathophysiology of bone disease in gastrointestinal disease

Reduced bone mass and the increased risk of fracture in gastrointestinal diseases have a multifactorial pathogenesis. Undoubtedly, genetics play an important role, but other factors such as systemic inflammation, malnutrition, hypogonadism, glucocorticoid therapy in inflammatory bowel disease (IBD) and other lifestyle factors, such as smoking or being sedentary, may contribute to reduced bone mass. At a molecular level the proinflammatory cytokines that contribute to the intestinal immune response in IBD and probably also in coeliac disease are also known to enhance bone resorption. The discovery of the role of the receptor to activated NFkappaB (RANK) interaction with its ligand RANKL in orchestrating the balance between bone resorption and formation may link mucosal and systemic inflammation with bone remodelling, since RANK-RANKL are also involved in lymphopoiesis and T-cell apoptosis. Low circulating leptin in response to weight loss in any gastrointestinal disease may be an important factor in reducing bone mass. This report will summarize current concepts regarding gastrointestinal diseases (primarily IBD, coeliac disease and postgastrectomy states) and low bone mass and fracture.

Longitudinal study of bone mineral density in patients with Crohn's disease

Osteoporosis is frequent in Crohn's disease. The aim of the study was to assess the rate of bone loss over time retrospectively and the influence of disease-related factors on bone loss. Twenty-nine patients (8 male), admitted for repeated bone mineral density assessments (BMD) were enrolled. BMD measured by dual energy x-ray absoptiometry was expressed in grams per square centimeter, and as sex- and age-matched Z score. The mean interval between BMD assessments was 41 months, during which period 27 patients used corticosteroids (mean dose 8.6 g) and 21 patients some form of bone protective medication. Initial Z scores at a mean age of 41 years were significantly below zero (spine -1.6 +/- 1.4; femur -1.4 +/- 1.4). Over time, no change in absolute BMD was observed accompanied by an improvement in Z scores. At the same time, an increase in body weight and a decrease in erythrocyte sedimentation rate (ESR) was observed. Multilinear regression analysis demonstrated change in ESR as independent predictor for change in femoral Z score. In conclusion, low BMD is frequent in Crohn's disease, but decline of BMD over time was not found, despite ongoing use of corticosteroids.

Body composition in patients with inflammatory bowel disease: a population-based study

OBJECTIVE

Weight loss and nutritional depletion are common features of inflammatory bowel disease. Our aim was to assess body composition in patients with Crohn's disease (CD) and ulcerative colitis (UC) and to evaluate possible differences between the patient groups and healthy subjects.

METHODS

A total of 60 patients with CD, 60 patients with UC, and 60 healthy subjects were investigated. Each group consisted of 24 men and 36 women. Body composition was measured by dual x-ray absorptiometry and Z scores were obtained by comparison to age- and sex-matched normal values.

RESULTS

Bone mineral content and lean body mass were significantly lower in patients with CD compared with patients with UC and healthy subjects. The body composition of CD men was more strongly affected than that of women. UC patients had significantly higher fat mass and body mass index than patients with CD and healthy subjects. There was no difference in the percentage of fat mass between the two patient groups. Corticosteroid treatment and smoking had a negative impact on bone mineral content and lean body mass in CD patients independently of each other.

CONCLUSIONS

CD was associated with disturbances in body composition: both bone mineral content and lean body mass were significantly reduced, especially in men with CD. Corticosteroid therapy and smoking had a significant influence on body composition in patients with CD. When studying the effects of inflammatory bowel disease on body composition and nutritional status, patients with CD and UC should be evaluated separately.

Glucocorticoid-induced osteoporosis

Therapeutic use of glucocorticoids can lead to many well-known adverse events. Of all potential serious side effects, glucocorticoid-induced osteoporosis (GIOP) is one of the most devastating complications of protracted glucocorticoid therapy in rheumatoid arthritis. GIOP is the most common form of drug-induced osteoporosis. Although much has been written about the association of glucocorticoids with bone disease among patients with chronic inflammatory conditions, many issues remain unsettled. This article focuses on areas of continued controversies, including the epidemiology and pathogenesis of GIOP, specification of a "safe" dose, methods for diagnosis of GIOP, and an evidence-based approach for GIOP prevention.

Mechanisms by which nutritional disorders cause reduced bone mass in adults

Nutritional disorders that cause bone loss in adults include disordered eating behaviors (female athlete triad and anorexia nervosa), gastrointestinal diseases (celiac sprue, inflammatory bowel disease, and other malabsorption syndromes), alcoholism, and hypervitaminosis A. These disorders exert their effects on bone through a number of mechanisms, including estrogen deficiency. Deficiencies of anabolic hormones may also be important, including insulin-like growth factor I (IGF-I), a nutritionally regulated bone trophic factor. In addition, low weight itself is a risk factor for bone loss and decreased bone formation. Reduced calcium and vitamin D availability, with resultant secondary hyperparathyroidism, is another important mechanism of bone loss in nutritional disorders. This review discusses nutritional causes of reduced bone mass in adults and how nutritional disorders exert deleterious effects on the skeleton.

Nutrition in Crohn disease

Nutrition plays an important role in the pathogenesis, treatment, and morbidity of Crohn disease. Approximately two thirds to three fourths of hospitalized patients with active disease and one fourth of outpatients with Crohn disease are malnourished. Malnutrition, which can be present even when Crohn disease is in remission, can affect growth, cellular and humoral immunity, bone density, and wound healing. Decreased nutrient intake, malabsorption, drug-nutrient interactions, anorexia, and protein-losing enteropathy can all contribute to the protein-calorie malnutrition and other specific nutrient deficiencies seen in Crohn disease. Therefore, by preventing and correcting nutrient deficiencies, nutritional therapy is an important component in the overall management of patients with Crohn disease.

Review article: nutrition and adult inflammatory bowel disease

Major advances in the understanding of the aetio-pathogenesis and genetics of inflammatory bowel disease have been accompanied by an escalation in the sophistication of immunomodulatory inflammatory bowel disease therapeutics. However, the basic 'triple' therapy (5-aminosalicylates, corticosteroids, azathioprine) and nutrition have maintained their central role in the management of patients with inflammatory bowel disease over recent decades. This review provides an overview of the supportive and therapeutic perspectives of nutrition in adult inflammatory bowel disease. The objective of supportive nutrition is to correct malnutrition in terms of calorie intake or specific macro- or micronutrients. Of particular clinical relevance is deficiency in calcium, vitamin D, folate, vitamin B12 and zinc. There is justifiably a growing sense of unease amongst clinicians and patients with regard to the long-term use of corticosteroids in inflammatory bowel disease. This, rather than arguments about efficacy, should be the catalyst for revisiting the use of enteral nutrition as primary treatment in Crohn's disease. Treatment failure is usually related to a failure to comply with enteral nutrition. Potential factors that militate against successful completion of enteral nutrition are feed palatability, inability to stay on a solid-free diet for weeks, social inconvenience and transient feed-related adverse reactions. Actions that can be taken to improve treatment outcome include the provision of good support from dietitians and clinicians for the duration of treatment and the subsequent 'weaning' period. There is evidence to support a gradual return to a normal diet through exclusion-re-introduction or other dietary regimen following the completion of enteral nutrition to increase remission rates. We also review the evidence for emerging therapies, such as glutamine, growth factors and short-chain fatty acids. The future may see the evolution of enteral nutrition into an important therapeutic strategy, and the design of a 'Crohn's disease-specific formulation' that is individually tailored, acceptable to patients, cost-effective, free from adverse side-effects and combines enteral nutrition with novel pre- and pro-biotics and other factors.

Examination, prevention and treatment of osteoporosis in patients with inflammatory bowel disease: recommendations and reality

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. Our aim was to evaluate the current practices of examination, prevention and treatment of osteoporosis in IBD patients in a routine clinical setting.

METHODS

A total of 154 consecutive patients with IBD (63 female, 91 male; 36 ulcerative colitis, 115 Crohn's disease, 3 indeterminate colitis), referred to two gastroenterological units for scheduled follow-up examinations, were included. Patient charts were evaluated regarding bone densitometry already performed and any prophylactic or therapeutic interventions in cases of low bone mineral density.

RESULTS

Bone mineral density (BMD) measurements had been performed only in 38 patients (25%). BMD was abnormally low in 27 of the examined patients (71%), 20 of whom had osteopenia and seven had osteoporosis. Among the subgroup of patients on long-term steroid therapy (77 patients), 30 had been referred to bone densitometry during the course of disease, and 21 of them were found to have low bone mineral density. Preventive measures were prescribed in 12 patients (9% of the whole study population). In the majority of the patients with low bone mineral density, calcium and vitamin D were used as treatment.

CONCLUSIONS

Despite the high prevalence of osteopenia and osteoporosis in patients with IBD, only a minority of these patients were included in a structured program in accordance with modern guidelines for diagnosing and preventing this extraintestinal complication in a routine clinical setting.

High prevalence of osteoporotic vertebral fractures in patients with Crohn's disease

BACKGROUND AND AIMS

Osteopenia and osteoporosis are frequent in Crohn's disease. However, there are few data on related vertebral fractures. Therefore, we evaluated prospectively the prevalence of osteoporotic vertebral fractures in these patients.

METHODS

A total of 293 patients were screened with dual energy x ray absorptiometry of the lumbar spine (L1-L4) and proximal right femur. In 156 patients with lumbar osteopenia or osteoporosis (T score <-1), x ray examinations of the thoracic and lumbar spine were performed. Assessment of fractures included visual reading of x rays and quantitative morphometry of the vertebral bodies (T4-L4), analogous to the criteria of the European Vertebral Osteoporosis Study.

RESULTS

In 34 (21.8%; 18 female) of 156 Crohn's disease patients with reduced bone mineral density, 63 osteoporotic vertebral fractures (50 fx. (osteoporotic fracture with visible fracture line running into the vertebral body and/or change of outer shape) and 13 fxd. (osteoporotic fracture with change of outer shape but without visible fracture line)) were found, 50 fx. in 25 (16%, 15 female) patients and 13 fxd. in nine (5.8%, three female) patients. In four patients the fractures were clinically evident and associated with severe back pain. Approximately one third of patients with fractures were younger than 30 years. Lumbar bone mineral density was significantly reduced in patients with fractures compared with those without (T score -2.50 (0.88) v -2.07 (0.66); p<0.025) but not at the hip (-2.0 (1.1) v -1.81 (0.87); p=0.38). In subgroups analyses, no significant differences were observed.

CONCLUSIONS

In patients with Crohn's disease and reduced bone mineral density, the prevalence of vertebral fractures-that is, manifest osteoporosis-was strikingly high at 22%, even in those aged less than 30 years, a problem deserving further clinical attention.

Metabolic bone disease is present at diagnosis in patients with inflammatory bowel disease

AIM

To establish whether bone disease is present at diagnosis in inflammatory bowel disease and to identify contributory metabolic abnormalities.

METHODS

Newly diagnosed patients with inflammatory bowel disease (19 males, 15 females; mean age, 44 years; range, 17-79 years; 23 ulcerative colitis, 11 Crohn's disease) were compared against standard reference ranges and a control group with irritable bowel syndrome (eight males, 10 females; mean age, 40 years; range, 19-64 years). Bone mineral density (g/cm2, dual-energy X-ray absorptiometry: lumbar spine and femoral neck) and biochemical bone markers were measured.

RESULTS

Femoral neck bone mineral density, T- and Z-scores (mean +/- s.d., respectively) were lower in inflammatory bowel disease patients than in irritable bowel syndrome controls (0.78 +/- 0.12 vs. 0.90 +/- 0.16, P = 0.0046; - 0.88 +/- 0.92 vs. 0.12 +/- 1.17, P = 0.0018; - 0.30 +/- 0.89 vs. 0.61 +/- 1.10, P = 0.0030). Lumbar spine bone mineral density and T-scores were also significantly lower in patients than controls (0.98 +/- 0.15 vs. 1.08 +/- 0.13, P = 0.0342; - 1.05 +/- 1.39 vs. - 0.14 +/- 1.19, P = 0.0304). Compared with controls, the urinary deoxypyridinoline : creatinine ratio was increased (7.66 vs. 5.70 nmol/mmol, P = 0.0163) and serum 25-hydroxy vitamin D was decreased (18.7 vs. 28.5 micro g/L, P = 0.0016); plasma osteocalcin and serum parathyroid hormone did not differ (P > 0.05).

CONCLUSIONS

The bone mineral density is reduced at diagnosis, prior to corticosteroid treatment, in both Crohn's disease and ulcerative colitis. Our data suggest that this is attributable to increased resorption rather than decreased bone formation.

Corticosteroid-induced osteoporosis: does it occur in patients with Crohn's disease?

OBJECTIVE

In Crohn's disease, osteoporosis is frequently found. However, the etiology of osteoporosis remains unclear. The aim of this study was to determine disease-related variables predictive for impaired bone mineral density (BMD).

METHODS

A total of 91 patients with Crohn's disease who were admitted for BMD assessment were enrolled in the study. BMD was measured at the femoral neck and lumbar spine by dual energy x-ray absorptiometry (DXA). Results were expressed as T-score and as age- and sex-matched Z-score. Data were obtained by a questionnaire and from patients' medical records. Stepwise linear regression analysis was used to determine independent variables predictive for BMD.

RESULTS

Mean age at BMD assessment was 41 +/- 12 yr, duration of disease 11.6 +/- 8.5 yr, and body mass index (BMI) 23.0 +/- 4.1 kg/m2. The cumulative dose of steroids used was 18.7 +/- 19.2 g. Mean Z-scores were less than zero (spine, -1.1 +/- 1.3 SD; femur, -1.1 +/- 1.2 SD; p < 0.0001). A total of 27 patients (30%) fulfilled the World Health Organization criteria for osteoporosis and 46 patients (50%) for osteopenia. Osteoporotic patients used more corticosteroids and had longer duration of disease, lower BMI, and more bowel resections than patients with normal BMD. However, in the linear regression analysis, the only significant independent predictors for BMD of the lumbar spine and femoral neck were BMI and history of bowel resections. BMI and history of resections together accounted for 28% of BMD Z-scores.

CONCLUSIONS

BMI and a history of bowel resections were significant predictive variables for BMD. Despite the high dose of steroids used in this study, no detrimental effect could be demonstrated as independent predictor for osteoporosis.

Long-term fracture risk in patients with Crohn's disease: a population-based study in Olmsted County, Minnesota

BACKGROUND & AIMS

Osteoporosis is common in patients with Crohn's disease, but less is known about their risk of actual fractures.

METHODS

The medical records of all 238 Olmsted County, Minnesota, residents diagnosed with Crohn's disease between 1940 and 1993 were reviewed for evidence of subsequent fractures compared with a control group of county residents matched by age and sex. The risk ratio of fracture in patients relative to controls was estimated using the Cox proportional hazards regression model. The cumulative incidence of fracture following diagnosis was estimated using the Kaplan-Meier method.

RESULTS

Sixty-three patients had 117 different fractures. The cumulative incidence of any fracture from the time of diagnosis onward was 36% at 20 years versus 32% in controls (P = 0.792). Compared with controls, the overall risk ratio for any fracture was 0.9 (95% confidence interval [CI], 0.6-1.4), whereas the relative risk for an osteoporotic fracture was 1.4 (95% CI, 0.7-2.7). The risk ratio for thoracolumbar vertebral fracture was 2.2 (95% CI, 0.9-5.5). Cox proportional hazards regression identified only age as a significant clinical predictor of fracture risk (hazard ratio per 10-year increase in age, 1.3; 95% CI, 1.1-1.5). Specifically, use of corticosteroids and surgical resection did not predict risk of fracture among these unselected patients with Crohn's disease from the community.

CONCLUSIONS

In this population-based inception cohort of patients with Crohn's disease, the risk of fracture was not elevated relative to age- and sex-matched controls.

Discordance between the degree of osteopenia and the prevalence of spontaneous vertebral fractures in Crohn's disease

BACKGROUND

A high prevalence of osteoporosis has been noted in Crohn's disease, but data about fractures are scarce.

METHODS

The relationship between low bone mineral density and the prevalence of vertebral fractures was studied in 271 patients with ileo-caecal Crohn's disease in a large European/Israeli study. One hundred and eighty-one currently steroid-free patients with active Crohn's disease (98 completely steroid-naive) and 90 steroid-dependent patients with inactive or quiescent Crohn's disease were investigated by dual X-ray absorptiometry scan of the lumbar spine, a standardized posterior/anterior and lateral X-ray of the thoracic and lumbar spine, and an assessment of potential risk factors for osteoporosis.

RESULTS

Thirty-nine asymptomatic fractures were seen in 25 of 179 steroid-free patients (14.0%; 27 wedge, 12 concavity), and 17 fractures were seen in 13 of 89 steroid-dependent patients (14.6%; 14 wedge, three concavity). The prevalence of fractures in steroid-naive patients was 12.4%. The average bone mineral density, expressed as the T-score, of patients with fractures was not significantly different from that of those without fractures (-0.759 vs. -0.837; P=0.73); 55% of patients with fractures had a normal T-score. The bone mineral density was negatively correlated with lifetime steroids, but not with previous bowel resection or current disease activity. The fracture rate was not correlated with the bone mineral density (P=0.73) or lifetime steroid dose (P=0.83); in women, but not in men, the fracture rate was correlated with age (P=0.009).

CONCLUSIONS

The lack of correlation between the prevalence of fractures on the one hand and the bone mineral density and lifetime steroid dose on the other necessitates new hypotheses for the pathogenesis of the former.

Screening for osteoporosis in patients with inflammatory bowel disease by using urinary N-telopeptides

BACKGROUND

Patients with inflammatory bowel disease are at increased risk of osteoporosis.

DESIGN AND METHODS

We carried out a prospective study of bone mineral density and biochemical markers of bone metabolism like osteocalcin and urinary N-telopeptides in 72 patients with inflammatory bowel disease and evaluated if one of these markers detects osteoporosis. In addition, bone mineral density and N-telopeptides were analysed retrospectively in a second series of 93 patients with inflammatory bowel disease in order to assess predictive values found in the first patient group in an independent sample.

RESULTS

Multiple linear regression showed that N-telopeptides (P < 0.0001) and total white blood cell count (P = 0.006) correlated negatively with the bone mineral density of the lumbar spine and only N-telopeptides (P = 0.005) correlated negatively with the bone mineral density of the femoral neck. Using receiver operator characteristic curves N-telopeptide concentrations of > 40 (30) nmol N-telopeptides/mmol creatinine were chosen as best cut-off values to exclude osteoporosis at the lumbar spine (femoral neck). Using these cut-off values a negative predictive value of 100% (100%) and a positive predictive value of 37.5% (27.9%) were found in the first group, and a negative predictive value of 95.2% (96%) and a positive predictive value of 15.6% (23.3%) in the second, independent group of patients.

CONCLUSION

Our data suggest that N-telopeptide levels could be used as a tool for the screening of osteoporosis and for selecting those inflammatory bowel disease patients where bone mineral density measurement is indicated.

Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D with or without fluoride

BACKGROUND

Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation.

AIM

To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D.

METHODS

In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups.

RESULTS

Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P < 0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity.

CONCLUSIONS

Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

Secondary causes of osteoporosis

Secondary causes of bone loss are not often considered in patients who are diagnosed as having osteoporosis. In some studies, 20% to 30% of postmenopausal women and more than 50% of men with osteoporosis have a secondary cause. There are numerous causes of secondary bone loss, including adverse effects of drug therapy, endocrine disorders, eating disorders, immobilization, marrow-related disorders, disorders of the gastrointestinal or biliary tract, renal disease, and cancer. Patients who have undergone organ transplantation are also at increased risk for osteoporosis. In many cases, the adverse effects of osteoporosis are reversible with appropriate intervention. Because of the many treatment options that are now available for patients with osteoporosis and the tremendous advances that have been made in understanding the pathogenesis and diagnosis of the condition, it is important that medical disorders are recognized and appropriate interventions are undertaken. This article provides the framework for understanding causes of bone loss and approaches to their management.

Corticosteroids in Crohn's disease

Crohn's disease is a lifelong illness characterized by chronic recurrent flares. The precise etiology of Crohn's disease is unknown. However, it appears to involve an enhanced systemic immune response and intensified local intestinal mucosal inflammatory activity, mediated through various inflammatory cells and an array of proinflammatory cytokines. Corticosteroids have been the mainstay of treatment of Crohn's disease. The controlled trials of the National Cooperative Crohn's Disease Study and the European Cooperative Crohn's Disease Study established that corticosteroids were effective for the induction of remission in Crohn's disease for the duration of the studies (6-17 wk). However, corticosteroids have not been shown to have an impact on the maintenance of long term remission in patients with Crohn's disease. In addition, they are associated with a high potential for dependence and serious toxic side effects. Alternative classes of medical therapy for Crohn's disease, including modified corticosteroids and a group of new biological therapies, have proven to be efficacious in the management of active and/or quiescent Crohn's disease.

Nutritional factors in inflammatory bowel disease

Dietary antigens may act as important stimuli of the mucosal immune system and have led to the study of nutritional therapy for IBD. Patients with active CD respond to bowel rest, along with total enteral nutrition or TPN. Bowel rest and TPN are as effective as corticosteroids at inducing remission for patients with active CD, although benefits are short-lived. Enteral nutrition is consistently less effective than conventional corticosteroids for treatment of active CD. Use of palatable, liquid polymeric diets in active CD is controversial, but these diets are of equal efficacy when compared with elemental diets. UC has not been treated effectively with either elemental diets or TPN. Fish oil contains n-3-PUFA, which inhibits production of proinflammatory cytokines and has some benefit in the treatment of CD. Topical applications of short-chain fatty acids have benefited diversion colitis and distal UC, whereas probiotics hold promise in the treatment of pouchitis.

Risk factors for low bone density in Crohn's disease

Osteopenia and osteoporosis are prevalent in patients with Crohn's disease (CD). We conducted a cross-sectional study on consecutive patients with CD to assess the prevalence and factors associated with low bone mass density (BMD). One hundred sixty-eight patients with CD were evaluated. Baseline demographics, medical and surgical history, calcium intake, physical activity, steroid use, Harvey Bradshaw Index, blood and urine tests, and dual-energy X-ray absorptiometry were obtained. Sixty-seven (40%) and seventy-five (45%) patients had osteopenia of the femur and spine, respectively. Ten to 11% of patients had osteoporosis. Of the 40 patients who never used steroids, 19 (48%) had osteopenia of the femur and 12 (30%) of the spine. Significant associations were found between BMD and age, body mass index, and serum magnesium. Lifetime steroid use was a weaker predictor of bone loss. Duration of disease did not correlate with BMD when adjusted for age. At follow-up at a mean of 2 years, BMD declined in the femur but not the spine. However, those with ongoing steroid use had lower spine BMD. A significant number of patients with CD have osteopenia. Age was the most important predictor of bone loss. Significant proportion of steroid naive patients had osteopenia, which implies that mechanisms other than steroid use are also involved in bone loss in CD. Disease activity, systemic inflammation, and hormonal and genetic factors may all be important determinants of bone loss in CD.

Extraintestinal manifestations of inflammatory bowel disease

Numerous extraintestinal diseases have been associated with IBD. The role of the gastrointestinal tract in host response to the foreign antigens present in the gut makes the enteric immune system highly susceptible to any external perturbation to the system. Dysregulation of the enteric immune response results in pathology in various organs outside of the gut. The site-specific manifestations of this immune response are not understood fully. Better understanding of the pathogenesis of IBD and the complex interactions between the gut immune system and the extraintestinal systems would provide insights into the development of many of these extraintestinal manifestations. Much is unknown about the presence of cardiac, pulmonary, and hematologic diseases in patients with IBD. True association or coincidental presence of the diseases in these organ systems with IBD requires better delineation. An important consideration in all patients with IBD presenting with extraintestinal manifestations should be a careful search for medication-related complications.

Treatments for Crohn's disease that minimise steroid doses are associated with a reduced risk of osteoporosis

Crohn's disease is associated with an increased prevalence of osteoporosis. Corticosteroids, commonly used to control exacerbations, appear to be a major risk factor for subsequent development of osteoporosis. Exclusion diets, avoiding foods that precipitate symptoms, frequently allow control of the disease avoiding the use of corticosteroids and may thereby reduce the risk of osteoporosis. To investigate this we performed bone mineral density measurements of the proximal femur and spine in 95 patients, 31 treated predominately by corticosteroids, 33 by dietary manipulation with a low life-time corticosteroid dose and 31 by treatments other than diets but also with a low life-time corticosteroid dose. In both groups with a low life-time corticosteroid dose bone mineral density was comparable to that of age-matched normal controls, whereas bone mineral density was significantly reduced in those treated predominately by corticosteroids. We conclude that corticosteroid therapy is an independent risk factor for osteoporosis in patients with Crohn's disease and should be used as little as possible.

Allelic variation at the interleukin 1beta gene is associated with decreased bone mass in patients with inflammatory bowel diseases

BACKGROUND

Interleukin 1beta (IL-1beta) and its natural antagonist have been implicated in the pathogenesis of inflammatory bowel disease (IBD). Both cytokines influence bone formation. IL-1beta stimulates osteoclast activity while interleukin 1 receptor antagonist (IL-1ra) enhances bone formation.

AIMS

To determine whether the decreased bone mass in IBD is related to gene polymorphisms coding for IL-1beta and IL-1ra, and thus identify patients with an increased risk.

METHODS

Bone mineral densitometry was performed at the femoral neck, lumbar spine, and the distal third of the radius in 75 IBD patients (34 men/41 women; 40.3 (1.6) years) and in 58 healthy controls (HC; 28 men/30 women; 32.4 (1.2) years). Values were correlated with the TaqI and AvaI gene polymorphisms in the IL1B and the variable number of tandem repeats gene polymorphism in the IL1RN gene.

RESULTS

In IBD patients, but not in HC, carriers of allele 2 at the AvaI gene polymorphism (IL1B-511*2) had significantly lower Z scores at the lumbar spine (-0.82 (0.13) v -0.29 (0.21) p=0.03) and the femoral neck (-0.59 (0.14) v 0.15 (0.19); p=0.003) than non-carriers. These patients also had a higher risk for osteopenia or osteoporosis at the femoral neck (odds ratio 3.63 (95% confidence interval 0.95-13.93)). No association was found between bone mass and the other gene polymorphisms analysed in IBD patients or in HC.

CONCLUSIONS

Our results suggest that genetic variability may be a major determinant of bone loss in IBD. Carriers of IL1B-511*2, who are hypersecretors of IL-1beta, have a higher risk of presenting with low bone mass in IBD. Screening for this allele may contribute to determination of the risk of bone loss at the time of disease onset.

Abnormal bone turnover in long-standing Crohn's disease in remission

BACKGROUND

A high prevalence of osteoporosis is found in patients with Crohn's disease. The pathogenesis of this condition seems to be multifactorial and its pathophysiology is still not completely understood.

AIM

To elucidate the pathophysiology of osteopenia in quiescent Crohn's disease.

METHODS

Bone turnover was studied in 26 patients (13 males and 13 females) with long-standing quiescent Crohn's disease and small bowel involvement. Bone mineral density was assessed by dual energy X-ray absorptiometry. Biochemical markers for bone formation (osteocalcin and bone-specific alkaline phosphatase) and for bone resorption (deoxypyridinoline and collagen type I C-terminal crosslinks) were measured. Urinary calcium excretion was determined.

RESULTS

Markers for bone formation were significantly lower in patients than in controls (osteocalcin: P= 0.027, bone-specific alkaline phosphatase: P < 0.001), but both bone resorption markers were not significantly different. Urine calcium excretion was significantly decreased in patients (P=0.002) compared to controls. Bone mineral density of the lumbar spine was significantly and inversely correlated with bone-specific alkaline phosphatase and collagen type I C-terminal crosslinks.

CONCLUSIONS

Bone turnover in long-standing Crohn's disease in clinical remission is characterized by suppressed bone formation and normal bone resorption. Urine calcium excretion is decreased. Hence, interventions and therapy should be directed towards the improvement of bone formation.

Low serum and bone vitamin K status in patients with longstanding Crohn's disease: another pathogenetic factor of osteoporosis in Crohn's disease?

BACKGROUND

A high prevalence of osteoporosis is reported in Crohn's disease. The pathogenesis is not completely understood but is probably multifactorial. Longstanding Crohn's disease is associated with a deficiency of fat soluble vitamins, among them vitamin K. Vitamin K is a cofactor in the carboxylation of osteocalcin, a protein essential for calcium binding to bone. A high level of circulating uncarboxylated osteocalcin is a sensitive marker of vitamin K deficiency.

AIMS

To determine serum and bone vitamin K status in patients with Crohn's disease and to elucidate its relationship with bone mineral density.

METHODS

Bone mineral density was measured in 32 patients with longstanding Crohn's disease and small bowel involvement, currently in remission, and receiving less than 5 mg of prednisolone daily. Serum levels of vitamins D and K, triglycerides, and total immunoreactive osteocalcin, as well as uncarboxylated osteocalcin ("free" osteocalcin) were determined. The hydroxyapatite binding capacity of osteocalcin was calculated. Data were compared with an age and sex matched control population.

RESULTS

Serum vitamin K levels of CD patients were significantly decreased compared with normal controls (p<0.01). "Free" osteocalcin was higher and hydroxyapatite binding capacity of circulating osteocalcin was lower than in matched controls (p<0.05 and p<0.001, respectively), indicating a low bone vitamin K status in Crohn's disease. In patients, an inverse correlation was found between "free" osteocalcin and lumbar spine bone mineral density (r=-0.375, p<0.05) and between "free" osteocalcin and the z score of the lumbar spine (r=-0.381, p<0.05). Multiple linear regression analysis showed that "free" osteocalcin was an independent risk factor for low bone mineral density of the lumbar spine whereas serum vitamin D was not.

CONCLUSIONS

The finding that a poor vitamin K status is associated with low bone mineral density in longstanding Crohn's disease may have implications for the prevention and treatment of osteoporosis in this disorder.

Bone mineral density in patients with recently diagnosed inflammatory bowel disease

BACKGROUND & AIMS

A high prevalence of osteoporosis is reported in inflammatory bowel disease (IBD), and its pathogenesis is not completely resolved. We investigated whether bone mineral density (BMD) in patients with IBD at diagnosis is lower than in population controls, and whether BMD differs between patients with Crohn's disease and those with ulcerative colitis.

METHODS

In 68 patients and 68 age- and gender-matched population controls, BMD of total body, spine, and hip was assessed using dual-energy x-ray absorptiometry within 6 months after establishing the diagnosis. Determinants for low BMD were assessed.

RESULTS

There were no significant differences in BMD (g/cm(2)) between patients and controls, and no significant differences in BMD between patients with either Crohn's disease or ulcerative colitis. Multivariate regression analysis showed that duration of complaints longer than 6 months before diagnosis (P = 0.041), age (P = 0.019), and body mass index less than 20 kg/m(2) (P = 0.006) significantly correlated with low BMD.

CONCLUSIONS

BMD in patients with recently diagnosed IBD was not significantly decreased compared with population controls. Subsequent development of osteoporosis in patients with IBD seems to be a phenomenon related to the disease process and/or the treatment modalities of IBD.

Alendronate increases lumbar spine bone mineral density in patients with Crohn's disease

BACKGROUND & AIMS

Low bone mineral density (BMD) is a common complication of Crohn's disease and may lead to increased morbidity and mortality because of fractures. We investigated the effect of treatment with the bisphosphonate alendronate on bone mass and markers of bone remodeling in patients with Crohn's disease.

METHODS

A 12-month double-blind, randomized, placebo-controlled trial examined the effect of a 10-mg daily dose of alendronate. Thirty-two patients with a bone mass T score of -1 of the hip or lumbar spine were studied. The main outcome measure was the difference in the mean percent change in BMD of the lumbar spine measured by dual-energy x-ray absorptiometry. Secondary outcome measures included changes in BMD of the hip and total body and biochemical markers of bone turnover (S-osteocalcin, urine pyridinoline, and urine deoxypyridinoline excretion).

RESULTS

Mean (+/-SEM) BMD of the lumbar spine showed an increase of 4.6% +/- 1.2% in the alendronate group compared with a decrease of 0.9% +/- 1.0% in patients receiving placebo (P < 0.01). BMD of the hip increased by 3.3% +/- 1.5% in the alendronate group compared with a smaller increase of 0.7% +/- 1.1% in the placebo group (P = 0.08). Biochemical markers of bone turnover decreased significantly in the alendronate group (P < 0.001). Alendronate was well tolerated, and there was no difference in adverse events among treatment groups.

CONCLUSIONS

Treatment with alendronate, 10 mg daily, significantly increased BMD in patients with Crohn's disease and was safe and well tolerated.

Bone mineral density and body composition in patients with ulcerative colitis

OBJECTIVE

Reduced bone mineral density (BMD) has been reported in ulcerative colitis (UC) patients, but body composition (fat and lean mass) has never been concomitantly studied. We sought to investigate BMD and body composition in a group of UC outpatients with the following characteristics: age 18-60 yr (men) and 18-45 yr (women); no intestinal resection; no immunosuppressive treatment; and regular menstruation.

METHODS

Whole body and subregional BMD and body composition in 43 UC patients (21 men, 22 women; male mean age, 36.5 [21-57] yr; female mean age, 35.3 [23-45] yr) and 121 healthy volunteers were studied by means of dual X-ray photon absorptiometry.

RESULTS

There were no differences in total and subregional BMD, or fat and lean mass between the patients and controls, except that the total and trunk lean mass of the UC women was lower than that in the normal controls. No correlation was found between lifetime steroid intake and BMD.

CONCLUSIONS

UC outpatients do not differ from normal subjects in terms of BMD and fat mass. Mild and moderate UC does not represent a risk factor for osteopenia.

Bone mass and gastrointestinal disease

Several gastrointestinal and liver diseases impair the absorption of calcium, phosphate, and/or vitamin D, and are associated with an increased incidence of bone disease. Changes in bone mineral density (BMD) using dual-energy X-ray absorptiomety (DXA) have been best studied in the malabsorptive disorder, celiac disease. Celiac disease is an inflammatory condition of the small intestine triggered by ingesting gluten present in wheat, rye, or barley. Chronic inflammation leads to intestinal atrophy and nutrient malabsorption. The disease affects the proximal small bowel; the site where calcium is best absorbed. About 70% of adults with celiac disease have abnormally low BMD values. Treatment with a gluten-free diet increases BMD, but not to normal values. As celiac disease may not be detected until adult life, the failure to reach normal BMD on a gluten-free diet can be explained, at least in part, by the failure to reach peak bone mass. All individuals with malabsorptive disorders should be screened for secondary bone disease. The development of easier and less expensive methods to assess BMD will facilitate screening those at risk for bone disease.

Decreased trabecular bone mineral density in newly diagnosed inflammatory bowel disease patients in Korea

BACKGROUND

Decreased bone mineral density (BMD) is common in Western patients with inflammatory bowel disease (IBD). However, BMD has never been studied in Asia where the demographic and socio-economic status are different from the West. The aim of this study was to investigate the prevalence and mechanisms of osteopenia in newly diagnosed Korean patients with IBD.

METHODS

We studied 14 patients with Crohn's disease (CD) and 25 patients with ulcerative colitis (UC), all of whom had never been treated with corticosteroids. Bone mineral density was measured in the lumbar spine and the femoral neck by dual energy X-ray absorptiometry. Biochemical parameters including serum osteocalcin, parathyroid hormone, plasma inactive and active vitamin D, and urinary deoxypyridinoline were measured.

RESULTS

The BMD Z score at the lumbar spine was lower both in CD and in UC patients, but there was no significant difference between the two groups. There was no significant difference in nutritional status or biochemical parameters of bone metabolism between patients with a normal BMD and those with a decreased BMD.

CONCLUSIONS

Low BMD at the lumbar spine is common in newly diagnosed Korean patients with IBD, a result which is similar to Western studies. The mechanism for low bone mass remains undetermined; however, nutritional status and hormonal parameters of bone metabolism, and ethnic differences are not likely to be an important factor in the pathogenesis of this bone loss.

Increased urinary N-telopeptide cross-linked type 1 collagen predicts bone loss in patients with inflammatory bowel disease

OBJECTIVE

Reduced bone mineral density (BMD) is common in patients with inflammatory bowel disease (IBD), but the factors associated with its longitudinal rate of change have not been established. We prospectively assessed the rate of change in BMD, and its association with biochemical markers of bone turnover.

METHODS

Twenty-two patients with Crohn's disease and 14 ulcerative colitis patients age 37.1 +/- 11.6 yr were followed for 2 yr. Lumbar spine (L2-L4) and femoral neck BMD were measured by dual x-ray absorptiometry at baseline and 24 months. Bone-specific alkaline phosphatase, osteocalcin, urinary N-telopeptide crosslinked type 1 collagen (NTx), parathyroid hormone, and 25-hydroxyvitamin-D were determined at baseline.

RESULTS

At baseline, 59% of Crohn's patients and 43% of ulcerative colitis patients were osteoporotic, with spine or femoral neck BMD T-score < -2.5. Spine BMD, and spine and femoral neck T-scores were lower and disease duration was longer in nine patients with ileal resection compared with nonoperated patients (0.84 +/- 0.15 g/cm2 vs 0.96 +/- 0.11 g/cm2, -3.0 +/- 1.5 vs -1.7 +/- 1.3, -3.2 +/- 1.5 vs -2.2 +/- 1.0, respectively; all p < 0.05). At 24 months, 13/36 (36%) and 14/36 (39%) patients experienced spinal and femoral neck bone loss, respectively, with mean annual percent BMD changes of -2.0% and -1.5%, respectively. NTx, a bone resorption marker, inversely correlated with spinal BMD rate of change (r = -0.4, p < 0.05). Using quartiles analysis, patients with the highest NTx (Q4) experienced the greatest decrease in spine BMD compared with patients with the lowest NTx (Q1).

CONCLUSIONS

Spine and femoral neck bone loss continues over time in more than one-third of IBD patients. Increased NTx level predicts spinal bone loss in IBD patients.