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Valvano M, Magistroni M, Cesaro N, Carlino G, Monaco S, Fabiani S, Vinci A, Vernia F, Viscido A, Latella G. Effectiveness of Vitamin D Supplementation on Disease Course in Inflammatory Bowel Disease Patients: Systematic Review With Meta-Analysis. Inflamm Bowel Dis 2024; 30:281-291. [PMID: 36579768 DOI: 10.1093/ibd/izac253] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The vitamin D role in bone metabolism is well known; however, recent evidence suggests the impact of vitamin D in immune modulation and its implications in immune-mediated diseases, including inflammatory bowel disease (IBD). METHOD We performed a systematic review with meta-analysis by a specific protocol (PROSPERO: CRD42022311184; March 2022, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=311184). Randomized clinical trials involving IBD patients treated with vitamin D supplementation, compared with placebo, that evaluated the risk of clinical relapse and disease activity were included. Literature search was performed using Medline, Scopus, and Cochrane CENTRAL through January 2022. RESULTS Out of 1448 articles, 12 (11 full-texts and 1 abstract) were included. Seven randomized clinical trials reported data on the clinical relapse as dichotomous outcome, while 7 studies reported data on disease activity expressed as continuous variables. The pooled risk ratio of clinical relapse was 0.64 (95% confidence interval, 0.46-0.89; I2 = 25%) among 458 IBD patients. However, this seems to be solid only in Crohn's disease (CD) patients. In fact, only 2 studies, involving 67 patients with ulcerative colitis, were included in the analysis. CD patients in clinical remission had a strong significant risk reduction in clinical relapse (risk ratio, 0.47; 95% confidence interval, 0.27-0.82; I2 = 0%), suggesting that it could be a specific subgroup with maximum clinical benefit of vitamin D supplementation. CONCLUSIONS This meta-analysis shows that vitamin D supplementation can reduce the risk of clinical relapse in IBD patients, especially in CD patients in clinical remission. In a subgroup analysis, it was not significant (due to small number of studies and low number of patients), and well-powered studies are needed, in particular for ulcerative colitis patients.
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Affiliation(s)
- Marco Valvano
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Magistroni
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Nicola Cesaro
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giorgio Carlino
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sabrina Monaco
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Stefano Fabiani
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Vinci
- Santo Spirito Hospital Clinical Management Unit, Local Health Authority Roma 1, Rome, Italy
| | - Filippo Vernia
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angelo Viscido
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Wei H, Zhao Y, Xiang L. Bone health in inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2023; 17:921-935. [PMID: 37589220 DOI: 10.1080/17474124.2023.2248874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic disease characterized by the presence of systemic inflammation, manifesting not only as gastrointestinal symptoms but also as extraintestinal bone complications, including osteopenia and osteoporosis. However, the association between IBD and osteoporosis is complex, and the presence of multifactorial participants in the development of osteoporosis is increasingly recognized. Unlike in adults, delayed puberty and growth hormone/insulin-like growth factor-1 axis abnormalities are essential risk factors for osteoporosis in pediatric patients with IBD. AREAS COVERED This article reviews the potential pathophysiological mechanisms contributing to osteoporosis in adult and pediatric patients with IBD and provides evidence for effective prevention and treatment, focusing on pediatric patients with IBD. A search was performed from PubMed and Web of Science inception to February 2023 to identify articles on IBD, osteoporosis, pediatric, and fracture risk. EXPERT OPINION A comprehensive treatment pattern based on individualized principles can be used to manage pediatric IBD-related osteoporosis.
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Affiliation(s)
- Hao Wei
- Thoracic Oncology Ward, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yihan Zhao
- Department of Cardiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lisha Xiang
- Thoracic Oncology Ward, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
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Peek CT, Ford CA, Eichelberger KR, Jacobse J, Torres TP, Maseda D, Latour YL, Piazuelo MB, Johnson JR, Byndloss MX, Wilson KT, Rathmell JC, Goettel JA, Cassat JE. Intestinal Inflammation Promotes MDL-1 + Osteoclast Precursor Expansion to Trigger Osteoclastogenesis and Bone Loss. Cell Mol Gastroenterol Hepatol 2022; 14:731-750. [PMID: 35835390 PMCID: PMC9420375 DOI: 10.1016/j.jcmgh.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) is characterized by severe gastrointestinal inflammation, but many patients experience extra-intestinal disease. Bone loss is one common extra-intestinal manifestation of IBD that occurs through dysregulated interactions between osteoclasts and osteoblasts. Systemic inflammation has been postulated to contribute to bone loss, but the specific pathologic mechanisms have not yet been fully elucidated. We hypothesized that intestinal inflammation leads to bone loss through increased abundance and altered function of osteoclast progenitors. METHODS We used chemical, T cell driven, and infectious models of intestinal inflammation to determine the impact of intestinal inflammation on bone volume, the skeletal cytokine environment, and the cellular changes to pre-osteoclast populations within bone marrow. Additionally, we evaluated the potential for monoclonal antibody treatment against an inflammation-induced osteoclast co-receptor, myeloid DNAX activation protein 12-associating lectin-1 (MDL-1) to reduce bone loss during colitis. RESULTS We observed significant bone loss across all models of intestinal inflammation. Bone loss was associated with an increase in pro-osteoclastogenic cytokines within the bone and an expansion of a specific Cd11b-/loLy6Chi osteoclast precursor (OCP) population. Intestinal inflammation led to altered OCP expression of surface receptors involved in osteoclast differentiation and function, including the pro-osteoclastogenic co-receptor MDL-1. OCPs isolated from mice with intestinal inflammation demonstrated enhanced osteoclast differentiation ex vivo compared to controls, which was abrogated by anti-MDL-1 antibody treatment. Importantly, in vivo anti-MDL-1 antibody treatment ameliorated bone loss during intestinal inflammation. CONCLUSIONS Collectively, these data implicate the pathologic expansion and altered function of OCPs expressing MDL-1 in bone loss during IBD.
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Affiliation(s)
- Christopher T. Peek
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caleb A. Ford
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Kara R. Eichelberger
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin Jacobse
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Teresa P. Torres
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Damian Maseda
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yvonne L. Latour
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - M. Blanca Piazuelo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joshua R. Johnson
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mariana X. Byndloss
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keith T. Wilson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee,Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Jeffrey C. Rathmell
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeremy A. Goettel
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James E. Cassat
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee,Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, Tennessee,Correspondence Address correspondence to: Dr Jim Cassat, Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, 1035 Light Hall, 2215-B Garland Ave, Nashville, TN, 37232. tel: (615) 936-6494.
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Herath M, Cohen A, Ebeling PR, Milat F. Dilemmas in the Management of Osteoporosis in Younger Adults. JBMR Plus 2022; 6:e10594. [PMID: 35079682 PMCID: PMC8771004 DOI: 10.1002/jbm4.10594] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Adi Cohen
- Department of Medicine Columbia University College of Physicians & Surgeons New York NY USA
| | - Peter R. Ebeling
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
| | - Frances Milat
- Department of Endocrinology Monash Health Clayton Victoria Australia
- Centre for Endocrinology & Metabolism Hudson Institute of Medical Research Clayton Victoria Australia
- Department of Medicine, School of Clinical Sciences Monash University Clayton Victoria Australia
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Abstract
INTRODUCTION the ESPEN guideline offers a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY the guideline is based on a extensive systematic review of the literature, but relies on expert opinion when objective data are lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process, in which uniformly positive responses (agree or strongly agree) were required. RESULTS IBD is increasingly common and potential dietary factors in its etiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally, if necessary) is strongly recommended. Routine provision of a special diet in IBD is not, however, supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not in Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis but is moderately well supported in Crohn's disease, especially in children, where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. CONCLUSIONS available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B), and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).
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The 25(OH)D3, but Not 1,25(OH)2D3 Levels Are Elevated in IBD Patients Regardless of Vitamin D Supplementation and Do Not Associate with Pain Severity or Frequency. Pharmaceuticals (Basel) 2021; 14:ph14030284. [PMID: 33809912 PMCID: PMC8004142 DOI: 10.3390/ph14030284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/31/2022] Open
Abstract
Due to its immunomodulatory effect, vitamin D has been associated with clinical parameters and outcomes in inflammatory bowel diseases (IBDs) which are chronic conditions of the gastrointestinal tract. Upon synthesis or digestion, vitamin D is metabolized in the liver to form 25(OH)D3, the major circulating metabolite. Further renal hydroxylation generates 1,25(OH)2D3, the most potent metabolite. Our aim was to examine the association between vitamin D levels, and its supplementation and pain intensity in 39 IBD patients and 33 healthy individuals. 25(OH)D3 and 1,25(OH)2D3 serum levels were measured. Each subject filled out visual analog scale (VAS) and Laitinen’s pain assessment scales. Laboratory results were obtained, and disease activity was assessed. Linear regression was employed to investigate the correlation between 25(OH)D3, 1,25(OH)2D3 and pain intensity, clinical activity parameters, C-reactive protein, disease duration, and dietary habits. In IBD patients, 25(OH)D3 was increased, whereas 1,25(OH)2D3 was not. Vitamin D3 supplementation did not influence their levels. No correlation was found between pain scores, disease activity, inflammatory status, disease duration or dietary habits and both forms of vitamin D. Elevated 25(OH)D3 and normal 1,25(OH)D3 were found in IBD patients as compared to the controls. We discovered no effect from supplementation and no association between pain severity and vitamin D.
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Abstract
PURPOSE OF REVIEW Inflammatory bowel disease (IBD) is associated with bone loss leading to osteoporosis and increased fracture risk. Bone loss is the result of changes in the balanced process of bone remodeling. Immune cells and cytokines play an important role in the process of bone remodeling and it is therefore not surprising that cytokines as observed in IBD are involved in bone pathology. This review discusses the role of cytokines in IBD-associated bone loss, including the consequences for treatment. RECENT FINDINGS Many studies have been conducted that showed the effect of a single cytokine on bone cells in vitro, including interleukin (IL)-1β, IL-6, IL-8, IL-12/IL-23, IL-17, IL-18, IL-32 and interferon-γ. Recently new members of the IL-1 family (IL-1F) have been related to IBD but the consequences for bone health remain uncertain. SUMMARY Overall, patients have to deal with a cocktail of cytokines, present in their serum. The combination of cytokines can affect bone cells differently compared to the effects of a single cytokine. This implicates that treatment, focused on reducing the inflammation could work best for bone health as well. Vitamin D might also play a role in this.
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Deng J, Silver Z, Huang E, Zheng E, Kavanagh K, Panicker J. The effect of calcium and vitamin D compounds on bone mineral density in patients undergoing glucocorticoid therapies: a network meta-analysis. Clin Rheumatol 2020; 40:725-734. [PMID: 32681366 DOI: 10.1007/s10067-020-05294-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/10/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION/OBJECTIVES The objective of our systematic review and network meta-analysis (NMA) is to investigate which vitamin D and/or calcium regimen would yield the greatest increase in lumbar spine, femoral neck, and total hip bone mineral density (BMD) in adult patients undergoing glucocorticoid therapy. METHOD We performed NMAs based on a prospectively developed protocol. A database search of MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL and Chinese databases were conducted for relevant randomized controlled trials (RCTs). Outcomes were percentage change in lumbar spine, femoral neck, and total hip BMD from baseline. RESULTS We included 16 RCTs containing 1073 eligible patients in our analysis. We found alfacalcidol+calcium to yield the greatest percentage increase in lumbar spine BMD (MD 6.05, 95% credible interval [CrI] - 4.18 to 16.18) compared to no treatment, and calcitriol+calcium to yield the greatest percentage increase in femoral neck BMD (MD 8.46, 95% CrI - 4.74 to 21.51) compared to no treatment. Cholecalciferol+calcium ranked first in terms of its ability to increase total hip BMD; however this finding needs to be interpreted with caution due to low sample sizes in the cholecalciferol+calcium treatment arm. None of the treatment arms ruled out the possibility of no effect for any outcome. CONCLUSIONS Alfacalcidol and calcitriol were the most efficacious treatment arms for increasing lumbar spine and femoral neck BMD, respectively. Our findings need to be validated by further investigations using larger, better-designed RCTs. Key Points •The efficacy of calcium/vitamin D compounds was examined using network meta-analyses. •Alfacalcidol + calcium yielded the greatest increase in lumbar spine BMD, calcitriol + calcium yielded the greatest increase in femoral neck BMD. •Future guidelines should place greater emphasis on the efficacy of different vitamin D compounds.
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Affiliation(s)
- Jiawen Deng
- Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Zachary Silver
- Faculty of Science, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
| | - Emma Huang
- Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Elena Zheng
- Faculty of Applied Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada
| | - Kyra Kavanagh
- Faculty of Science, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
| | - Jannusha Panicker
- Faculty of Science, University of Ottawa, 75 Laurier Ave E, Ottawa, ON, K1N 6N5, Canada
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Myint A, Sauk JS, Limketkai BN. The role of vitamin D in inflammatory bowel disease: a guide for clinical practice. Expert Rev Gastroenterol Hepatol 2020; 14:539-552. [PMID: 32543306 DOI: 10.1080/17474124.2020.1775580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that carries significant morbidity and mortality. Given the need to identify modifiable risk factors to prevent IBD development and to mitigate disease severity, vitamin D has become a major candidate of interest. AREAS COVERED In this review, we discuss the regulatory role played by vitamin D in intestinal immune homeostasis, updates in the recent literature exploring its role in de novo IBD pathogenesis and established IBD activity. We also discuss societal recommendations on its therapeutic role in maintaining bone health and future directions for studying its role in regulating disease activity. EXPERT OPINION In contrast to findings from earlier studies suggesting a causal role in IBD, recent findings indicate that vitamin D deficiency may be a sequela rather than a cause of IBD. Additionally, clinical trials exploring vitamin D therapy in reducing disease activity remain inconclusive thus far, with the current evidence best supporting a therapeutic role of vitamin D in bone health. Future studies are needed to clarify the role of vitamin D in IBD development and disease activity and to determine its therapeutic potential for IBD disease activity.
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Affiliation(s)
- Anthony Myint
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles, CA, USA
| | - Jenny S Sauk
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles, CA, USA
| | - Berkeley N Limketkai
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles, CA, USA
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van Bodegraven AA, Bravenboer N. Perspective on skeletal health in inflammatory bowel disease. Osteoporos Int 2020; 31:637-646. [PMID: 31822927 PMCID: PMC7075921 DOI: 10.1007/s00198-019-05234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/14/2019] [Indexed: 12/18/2022]
Abstract
Osteopenia and osteoporosis are common features in inflammatory bowel disease (IBD), comprising both Crohn's disease and ulcerative colitis. Moreover, Crohn's disease is associated with increased fracture risk. The etiology of bone loss in IBD is multifactorial. It includes insufficient intake or absorption of calcium, vitamin D, and potassium; smoking; a low peak bone mass; a low body mass index; and decreased physical activity. In several studies, it has been shown that elevated concentrations of systemic and local pro-inflammatory cytokines, including tumor necrosis factor alpha (TNF-α), interferon-γ (IFNγ), interleukin (IL)-1β, IL-4, IL-5, IL-6, IL-13, and IL-17, present in IBD patients are potentially detrimental for bone metabolism and may be responsible for bone loss and increased fracture risk. This perspective aims to review the current literature on the role of inflammatory factors in the pathophysiology of skeletal problems in IBD and to suggest potential treatment to improve bone health, based on a combination of evidence and clinical and pathophysiological reasoning.
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Affiliation(s)
- A. A. van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine(Co-MIK), Zuyderland MC, Sittard-Geleen-Heerlen, Dr H van der Hoffplein 1, 6162 BG Geleen, Netherlands
- Department of Gastroenterology, Amsterdam UMC, Location Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, Netherlands
| | - N. Bravenboer
- Department of Clinical Chemistry, Research Institute Amsterdam Movement Sciences Amsterdam UMC, Location Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, Netherlands
- Department of Internal Medicine, Endocrinology Section, Centre for Bone Quality LUMC, Albinusdreef 2, Leiden, 2333 ZA Netherlands
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Bischoff SC, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Forbes A. ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2020; 39:632-653. [PMID: 32029281 DOI: 10.1016/j.clnu.2019.11.002] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Krakow, Poland
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Kalina Stardelova
- University Clinic for Gasrtroenterohepatology, Clinal Centre "Mother Therese", Skopje, Macedonia
| | | | - Anthony E Wiskin
- Pediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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López-Sanromán A, Clofent J, Garcia-Planella E, Menchén L, Nos P, Rodríguez-Lago I, Domènech E. Reviewing the therapeutic role of budesonide in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:458-471. [PMID: 30007787 DOI: 10.1016/j.gastrohep.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/03/2018] [Indexed: 10/28/2022]
Abstract
Oral budesonide is a glucocorticoid of primarily local action. In the field of digestive diseases, it is used mainly in inflammatory bowel disease, but also in other indications. This review addresses the pharmacology, pharmacodynamics and therapeutic use of budesonide. Its approved indications are reviewed, as well as other clinical scenarios in which it could play a role, in order to facilitate its use and improve the accuracy of its prescription.
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Affiliation(s)
| | - Joan Clofent
- Servicio de Aparato Digestivo, Hospital de Sagunto, Sagunto, Valencia, España
| | | | | | - Pilar Nos
- Hospital Politècnic La Fe, València, España; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | | | - Eugeni Domènech
- Servei d'Aparell Digestiu, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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Radhakrishnan VM, Gilpatrick MM, Parsa NA, Kiela PR, Ghishan FK. Expression of Cav1.3 calcium channel in the human and mouse colon: posttranscriptional inhibition by IFNγ. Am J Physiol Gastrointest Liver Physiol 2017; 312:G77-G84. [PMID: 27932504 PMCID: PMC5283901 DOI: 10.1152/ajpgi.00394.2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 01/31/2023]
Abstract
It has been hypothesized that apically expressed L-type Ca2+ channel Cav1.3 (encoded by CACNA1D gene) contributes toward an alternative TRPV6-independent route of intestinal epithelial Ca2+ absorption, especially during digestion when high luminal concentration of Ca2+ and other nutrients limit TRPV6 contribution. We and others have implicated altered expression and activity of key mediators of intestinal and renal Ca2+ (re)absorption as contributors to negative systemic Ca2+ balance and bone loss in intestinal inflammation. Here, we investigated the effects of experimental colitis and related inflammatory mediators on colonic Cav1.3 expression. We confirmed Cav1.3 expression within the segments of the mouse and human gastrointestinal tract. Consistent with available microarray data (GEO database) from inflammatory bowel disease (IBD) patients, mouse colonic expression of Cav1.3 was significantly reduced in trinitrobenzene sulfonic acid (TNBS) colitis. In vitro, IFNγ most potently reduced Cav1.3 expression. We reproduced these findings in vivo with wild-type and Stat1-/- mice injected with IFNγ. The observed effect in Stat1-/- suggested a noncanonical transcriptional repression or a posttranscriptional mechanism. In support of the latter, we observed no effect on the cloned Cav1.3 gene promoter activity and accelerated Cav1.3 mRNA decay rate in IFNγ-treated HCT116 cells. While the relative contribution of Cav1.3 to intestinal Ca2+ absorption and its value as a therapeutic target remain to be established, we postulate that Cav1.3 downregulation in IBD may contribute to the negative systemic Ca2+ balance, to increased bone resorption, and to reduced bone mineral density in IBD patients.
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Affiliation(s)
| | | | - Nour Alhoda Parsa
- 1Department of Pediatrics, The University of Arizona, Tucson, Arizona; and
| | - Pawel R. Kiela
- 1Department of Pediatrics, The University of Arizona, Tucson, Arizona; and ,2Department of Immunobiology, The University of Arizona, Tucson, Arizona
| | - Fayez K. Ghishan
- 1Department of Pediatrics, The University of Arizona, Tucson, Arizona; and
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Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr 2016; 36:321-347. [PMID: 28131521 DOI: 10.1016/j.clnu.2016.12.027] [Citation(s) in RCA: 378] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. RESULTS IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. CONCLUSIONS Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).
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Affiliation(s)
- Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, James Watson Road, Norwich, NR4 7UQ, United Kingdom.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Office Sp-3460, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050, Skawina, Krakau, Poland.
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach-Tikva, 49202, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Centre "Mother Therese", Mother Therese Str No 18, Skopje, Republic of Macedonia.
| | - Nicolette Wierdsma
- VU University Medical Center, Department of Nutrition and Dietetics, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anthony E Wiskin
- Paediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
| | - Stephan C Bischoff
- Institut für Ernährungsmedizin (180) Universität Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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Clinical Course of Bone Metabolism Disorders in Patients with Inflammatory Bowel Disease: A 5-Year Prospective Study. Inflamm Bowel Dis 2016; 22:1929-36. [PMID: 27135482 DOI: 10.1097/mib.0000000000000815] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The clinical course of bone mineral density (BMD) disorders and the efficacy of treatment of osteopenia and osteoporosis have been poorly studied in patients with inflammatory bowel disease (IBD). The objective was to study the course of BMD disorders in patients with IBD, analyze the factors influencing their development, and assess the effect of treatment with calcium, vitamin D, and bisphosphonates. METHODS Consecutive patients with IBD were included and followed up for 5 years. After a baseline densitometry, calcium (1000 mg/d) and vitamin D (800 IU/d) were administered to patients with osteopenia; bisphosphonates to patients with osteoporosis; and patients with normal BMD were only followed-up. After completing the follow-up period, a second densitometry was performed. RESULTS One hundred patients were initially included, 60% having a low BMD (44% osteopenia and 16% osteoporosis). Fifty-eight patients completed the follow-up period. At baseline, osteopenia was more frequently found in Crohn's disease than in ulcerative colitis (63% versus 21%, P < 0.05). In patients with normal BMD at baseline, age, smoking habit, and the presence of flares during follow-up were associated with the development of osteopenia. Treatment with calcium and vitamin D improved the hip T-score in patients with osteopenia (-1.03 versus -0.58, P < 0.001) and bisphosphonates provided the same improvement (-1.482 versus -1.072, P < 0.05) in patients with osteoporosis. CONCLUSIONS Age, smoking habit, and IBD activity negatively influence the clinical course of BMD. Treatment with calcium and vitamin D improves hip T-score in patients with osteopenia whereas bisphosphonates improve hip T-score in patients with osteoporosis.
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Szilagyi A, Galiatsatos P, Xue X. Systematic review and meta-analysis of lactose digestion, its impact on intolerance and nutritional effects of dairy food restriction in inflammatory bowel diseases. Nutr J 2016; 15:67. [PMID: 27411934 PMCID: PMC4942986 DOI: 10.1186/s12937-016-0183-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Relationships between inflammatory bowel disease and lactose containing foods remain controversial and poorly defined regarding symptoms, nutritional outcomes, and epidemiologic associations for lactose maldigestion. METHODS A literature review was performed using Pub Med, Cochrane library and individual references, to extract data on lactose maldigestion prevalence in inflammatory bowel diseases. A meta-analysis was done using selected articles, to determine odds ratios of maldigestion. Information was collected about symptoms, impact on pattern of dairy food consumption, as well as the effects of dairy foods on the course of inflammatory bowel diseases. RESULTS A total of 1022 articles were evaluated, 35 articles were retained and 5 studies were added from review articles. Of these 17 were included in meta-analysis which showed overall increased lactose maldigestion in both diseases. However increased risk on sub analysis was only found in Crohn's in patients with small bowel involvement. Nine additional studies were reviewed for symptoms, with variable outcomes due to confounding between lactose intolerance and lactose maldigestion. Fourteen studies were evaluated for dairy food effects. There was a suggestion that dairy foods may protect against inflammatory bowel disease. Nutritional consequences of dairy restrictions might impact adversely on bone and colonic complications. CONCLUSIONS Lactose maldigestion in inflammatory bowel disease is dependent on ethnic makeup of the population and usually not disease. No bias of increased disease prevalence was noted between lactase genotypes. Intolerance symptoms depend on several parameters besides lactose maldigestion. Dairy foods may decrease risks of inflammatory bowel disease. Dairy restrictions may adversely affect disease outcome.
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Affiliation(s)
- Andrew Szilagyi
- Division of Gastroenterology, Department of Medicine, Jewish General Hospital, Room E-110,3755 Cote Ste Catherine Rd, Montreal, QC H3T 1E2 Canada
| | - Polymnia Galiatsatos
- Division of Gastroenterology, Department of Medicine, Jewish General Hospital, Room E-110,3755 Cote Ste Catherine Rd, Montreal, QC H3T 1E2 Canada
| | - Xiaoqing Xue
- Department of Emergency Medicine, Jewish General Hospital, McGill University, Montreal, QC Canada
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Kenanidis E, Potoupnis ME, Kakoulidis P, Leonidou A, Sakellariou GT, Sayegh FE, Tsiridis E. Management of glucocorticoid-induced osteoporosis: clinical data in relation to disease demographics, bone mineral density and fracture risk. Expert Opin Drug Saf 2015; 14:1035-53. [PMID: 25952267 DOI: 10.1517/14740338.2015.1040387] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Patient selection and the treatment choice remain to be controversial. None of the proposed management guidelines are widely accepted. We evaluate the available clinical data, the efficacy of current medication and we propose an overall algorithm for managing GIOP. AREAS COVERED This article provides a critical review of in vivo and clinical evidence regarding GIOP and developing evidence-based algorithm of treatment. Data base used includes MEDLINE® (1950 to May 2014). EXPERT OPINION Patient-specific treatment is the gold standard of care. Glucocorticoid (GC)-treated patients must comply with a healthy lifestyle and receive 1000 mg of calcium and at least 800 mg of Vitamin D daily. Bisphosphonate (BP) therapy is the current standard of care for prevention and treatment of GIOP. Most of bisphosphonates demonstrated benefit in lumbar bone mineral density (BMD) and some in hip BMD. Alendronate, risedronate and zoledronate showed vertebral anti-fracture efficacy in postmenopausal women and men. Scarce data however when compared head to head with BP efficacy. In post-menopausal women, early antiresorptive BP treatment appears to be efficient and safe. In premenopausal women and patients at high risk of fracture receiving long-term GC therapy however, teriparitide may be advised alternatively.
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Affiliation(s)
- Eustathios Kenanidis
- Aristotle University Medical School, Academic Orthopaedic Unit , Thessaloniki , Greece
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Effect of phylloquinone (vitamin K1) supplementation for 12 months on the indices of vitamin K status and bone health in adult patients with Crohn's disease. Br J Nutr 2014; 112:1163-74. [PMID: 25181575 DOI: 10.1017/s0007114514001913] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although epidemiological findings support a role for vitamin K status in the improvement of bone indices in adult patients with Crohn's disease (CD), this needs to be confirmed in double-blind, randomised controlled trials (RCT) with phylloquinone (vitamin K1). By conducting two RCT, the present study aimed to first establish whether supplementation with 1000 μg of phylloquinone daily near-maximally suppresses the percentage of undercarboxylated osteocalcin in serum (%ucOC; marker of vitamin K status) in adult patients with CD currently in remission as it does in healthy adults and second determine the effect of supplementation with phylloquinone at this dose for 12 months on the indices of bone turnover and bone mass. The initial dose-ranging RCT was conducted in adult patients with CD (n 10 per group) using 0 (placebo), 1000 or 2000 μg of phylloquinone daily for 2 weeks. In the main RCT, the effect of placebo v. 1000 μg vitamin K/d (both co-administered with Ca (500 mg/d) and vitamin D3 (10 μg/d)) for 12 months (n 43 per group) on the biochemical indices of bone turnover (determined by enzyme immunoassay) and bone mass (determined by dual-energy X-ray absorptiometry) were investigated. At baseline, the mean %ucOC was 47 %, and this was suppressed upon supplementation with 1000 μg of phylloquinone daily ( - 81 %; P< 0·01) and not suppressed further by 2000 μg of phylloquinone daily. Compared with the placebo, supplementation with 1000 μg of phylloquinone daily for 12 months had no significant effect (P>0·1) on bone turnover markers or on the bone mass of the lumbar spine or femur, but modestly increased (P< 0·05) the bone mass of the total radius. Despite near maximal suppression of serum %ucOC, supplementation with 1000 μg of phylloquinone daily (with Ca and vitamin D3) had no effect on the indices of bone health in adult CD patients with likely vitamin K insufficiency.
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Vernia P, Loizos P, Di Giuseppantonio I, Amore B, Chiappini A, Cannizzaro S. Dietary calcium intake in patients with inflammatory bowel disease. J Crohns Colitis 2014; 8:312-7. [PMID: 24090907 DOI: 10.1016/j.crohns.2013.09.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/23/2013] [Accepted: 09/07/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Osteopenia and increased risk for fractures in IBD result from several factors. AIM OF THE STUDY To investigate the dietary intake of calcium in IBD patients. METHODS A 22-item quantitative validated frequency food questionnaire was used for quantifying dietary calcium in relation to gender and age, in 187 IBD patients, 420 normal- and 276 diseased controls. STATISTICAL ANALYSIS Mann-Whitney, chi-square- and T-tests. RESULTS The mean calcium intake was 991.0 ± 536.0 (105.8% Recommended Daily Allowances) and 867.6 ± 562.7 SD mg/day (93.8% RDA) in healthy and diseased controls, and 837.8 ± 482.0 SD mg/day (92.7% RDA) in IBD, P<0.001. Calcium intake was high in celiac disease (1165.7 ± 798.8 SD mg/day, 120% RDA), and non-significantly lower in ulcerative colitis than in Crohn's disease (798.7 ± 544.1 SD mg/day vs 881.9 ± 433.0). CD and UC females, but not males, had a mean calcium intake well under RDA. In all study groups the intake was lower in patients believing that consumption of lactose-containing food induced symptoms, versus those who did not (105.8% vs 114.3% RDA in normal controls; 100.4% vs 87.6% RDA in IBD). CONCLUSIONS Diet in IBD patients contained significantly less calcium than in healthy controls. Gender and age, more than diagnosis, are central in determining inadequate calcium intake, more so in IBD. Self-reported lactose intolerance, leading to dietary restrictions, is the single major determinant of low calcium intake. Inadequate calcium intake is present in one third of IBD patients and represents a reversible risk factor for osteoporosis, suggesting the need for tailored nutritional advice in IBD.
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Affiliation(s)
- Piero Vernia
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy.
| | - Panagiotis Loizos
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Irene Di Giuseppantonio
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Barbara Amore
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Ambra Chiappini
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Santi Cannizzaro
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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Bjelakovic G, Gluud LL, Nikolova D, Whitfield K, Wetterslev J, Simonetti RG, Bjelakovic M, Gluud C. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev 2014:CD007470. [PMID: 24414552 DOI: 10.1002/14651858.cd007470.pub3] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Available evidence on the effects of vitamin D on mortality has been inconclusive. In a recent systematic review, we found evidence that vitamin D3 may decrease mortality in mostly elderly women. The present systematic review updates and reassesses the benefits and harms of vitamin D supplementation used in primary and secondary prophylaxis of mortality. OBJECTIVES To assess the beneficial and harmful effects of vitamin D supplementation for prevention of mortality in healthy adults and adults in a stable phase of disease. SEARCH METHODS We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index-Expanded and Conference Proceedings Citation Index-Science (all up to February 2012). We checked references of included trials and pharmaceutical companies for unidentified relevant trials. SELECTION CRITERIA Randomised trials that compared any type of vitamin D in any dose with any duration and route of administration versus placebo or no intervention in adult participants. Participants could have been recruited from the general population or from patients diagnosed with a disease in a stable phase. Vitamin D could have been administered as supplemental vitamin D (vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol)) or as an active form of vitamin D (1α-hydroxyvitamin D (alfacalcidol) or 1,25-dihydroxyvitamin D (calcitriol)). DATA COLLECTION AND ANALYSIS Six review authors extracted data independently. Random-effects and fixed-effect meta-analyses were conducted. For dichotomous outcomes, we calculated the risk ratios (RRs). To account for trials with zero events, we performed meta-analyses of dichotomous data using risk differences (RDs) and empirical continuity corrections. We used published data and data obtained by contacting trial authors.To minimise the risk of systematic error, we assessed the risk of bias of the included trials. Trial sequential analyses controlled the risk of random errors possibly caused by cumulative meta-analyses. MAIN RESULTS We identified 159 randomised clinical trials. Ninety-four trials reported no mortality, and nine trials reported mortality but did not report in which intervention group the mortality occurred. Accordingly, 56 randomised trials with 95,286 participants provided usable data on mortality. The age of participants ranged from 18 to 107 years. Most trials included women older than 70 years. The mean proportion of women was 77%. Forty-eight of the trials randomly assigned 94,491 healthy participants. Of these, four trials included healthy volunteers, nine trials included postmenopausal women and 35 trials included older people living on their own or in institutional care. The remaining eight trials randomly assigned 795 participants with neurological, cardiovascular, respiratory or rheumatoid diseases. Vitamin D was administered for a weighted mean of 4.4 years. More than half of the trials had a low risk of bias. All trials were conducted in high-income countries. Forty-five trials (80%) reported the baseline vitamin D status of participants based on serum 25-hydroxyvitamin D levels. Participants in 19 trials had vitamin D adequacy (at or above 20 ng/mL). Participants in the remaining 26 trials had vitamin D insufficiency (less than 20 ng/mL).Vitamin D decreased mortality in all 56 trials analysed together (5,920/47,472 (12.5%) vs 6,077/47,814 (12.7%); RR 0.97 (95% confidence interval (CI) 0.94 to 0.99); P = 0.02; I(2) = 0%). More than 8% of participants dropped out. 'Worst-best case' and 'best-worst case' scenario analyses demonstrated that vitamin D could be associated with a dramatic increase or decrease in mortality. When different forms of vitamin D were assessed in separate analyses, only vitamin D3 decreased mortality (4,153/37,817 (11.0%) vs 4,340/38,110 (11.4%); RR 0.94 (95% CI 0.91 to 0.98); P = 0.002; I(2) = 0%; 75,927 participants; 38 trials). Vitamin D2, alfacalcidol and calcitriol did not significantly affect mortality. A subgroup analysis of trials at high risk of bias suggested that vitamin D2 may even increase mortality, but this finding could be due to random errors. Trial sequential analysis supported our finding regarding vitamin D3, with the cumulative Z-score breaking the trial sequential monitoring boundary for benefit, corresponding to 150 people treated over five years to prevent one additional death. We did not observe any statistically significant differences in the effect of vitamin D on mortality in subgroup analyses of trials at low risk of bias compared with trials at high risk of bias; of trials using placebo compared with trials using no intervention in the control group; of trials with no risk of industry bias compared with trials with risk of industry bias; of trials assessing primary prevention compared with trials assessing secondary prevention; of trials including participants with vitamin D level below 20 ng/mL at entry compared with trials including participants with vitamin D levels equal to or greater than 20 ng/mL at entry; of trials including ambulatory participants compared with trials including institutionalised participants; of trials using concomitant calcium supplementation compared with trials without calcium; of trials using a dose below 800 IU per day compared with trials using doses above 800 IU per day; and of trials including only women compared with trials including both sexes or only men. Vitamin D3 statistically significantly decreased cancer mortality (RR 0.88 (95% CI 0.78 to 0.98); P = 0.02; I(2) = 0%; 44,492 participants; 4 trials). Vitamin D3 combined with calcium increased the risk of nephrolithiasis (RR 1.17 (95% CI 1.02 to 1.34); P = 0.02; I(2) = 0%; 42,876 participants; 4 trials). Alfacalcidol and calcitriol increased the risk of hypercalcaemia (RR 3.18 (95% CI 1.17 to 8.68); P = 0.02; I(2) = 17%; 710 participants; 3 trials). AUTHORS' CONCLUSIONS Vitamin D3 seemed to decrease mortality in elderly people living independently or in institutional care. Vitamin D2, alfacalcidol and calcitriol had no statistically significant beneficial effects on mortality. Vitamin D3 combined with calcium increased nephrolithiasis. Both alfacalcidol and calcitriol increased hypercalcaemia. Because of risks of attrition bias originating from substantial dropout of participants and of outcome reporting bias due to a number of trials not reporting on mortality, as well as a number of other weaknesses in our evidence, further placebo-controlled randomised trials seem warranted.
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Affiliation(s)
- Goran Bjelakovic
- Department of Internal Medicine, Medical Faculty, University of Nis, Zorana Djindjica 81, Nis, Serbia, 18000
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Efficacy and safety of medical therapy for low bone mineral density in patients with inflammatory bowel disease: a meta-analysis and systematic review. Clin Gastroenterol Hepatol 2014; 12:32-44.e5. [PMID: 23981521 DOI: 10.1016/j.cgh.2013.08.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/30/2013] [Accepted: 08/02/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) are at risk for osteoporosis and fracture. However, the efficacy of medical treatments for osteoporosis in increasing bone mineral density (BMD) in patients with IBD has not been well characterized. METHODS We conducted a meta-analysis and systematic review of controlled trials to evaluate the efficacy and safety of medical therapies used for low BMD in patients with IBD (Crohn's disease, ulcerative colitis, or indeterminate colitis). We searched MEDLINE, EMBASE, Google scholar, the University Hospital Medical Information Network (UMIN) Clinical Trials Registry, and Cochrane Central Register of Controlled Trials for studies that assessed the efficacy of medical treatment for low BMD in patients with IBD. We also manually searched abstracts from scientific meetings and bibliographies of identified articles for additional references. The primary outcome assessed was changes in BMD at the lumbar spine. We also collected data on hip BMD, numbers of new fractures, and adverse effects. Data were pooled by using random-effects models and by mixed-effects analysis for primary aims, when subgroup analysis by individual drug was possible. RESULTS We analyzed data from 19 randomized controlled studies; 2 used calcium and vitamin D as therapies, 13 used bisphosphonates, 4 used fluoride, 1 used calcitonin, and 1 used low-impact exercise. The pooled effect of bisphosphonates was greater than that of controls in increasing BMD at the lumbar spine (standard difference in means, 0.51; 95% confidence interval, 0.29-0.72) and hip (standard difference in means, 0.26; 95% confidence interval, 0.04-0.49) with comparable tolerability, and the risk of vertebral fractures was reduced. Fluoride increased lumbar spine BMD, but its ability to reduce risk of fracture was unclear. There was no evidence that the other interventions increased BMD. CONCLUSIONS On the basis of a meta-analysis, bisphosphonate is effective and well tolerated for the treatment of low BMD in patients with IBD and reduces the risk of vertebral fractures. There are insufficient data to support the efficacy of calcium and vitamin D, fluoride, calcitonin, or low-impact exercise. However, the small number of randomized controlled trials limited our meta-analysis.
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Lőrinczy K, Lakatos PL, Tóth M, Salamon Á, Nemes A, Csontos ÁA, Fekete B, Terjék O, Herszényi L, Juhász M, Tulassay Z, Miheller P. [Vitamin D level in Hungarian patients with inflammatory bowel diseases]. Orv Hetil 2013; 154:1821-1828. [PMID: 24212042 DOI: 10.1556/oh.2013.29750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Vitamin D has an important role in the immune regulation. Vitamin D is essential for innate and adaptive immune systems and it plays a significant role in the formation of immune tolerance, as well. AIM Vitamin D deficiency has been observed in patients with inflammatory bowel diseases in Western Europe, but there is no data available from Eastern Europe. METHOD The study included 169 patients with inflammatory bowel disease. RESULTS The median vitamin D level was 22.7±10.6 ng/ml. Only 20% of the patients had adequate vitamin D level (>30 ng/ml), 52% had vitamin D insufficiency (15-30 ng/ml), and 28% of them had severe vitamin D deficiency (<15 ng/ml). Vitamin D concentration failed to correlate with clinical activity indexes (partial Mayo score: r = -0.143; Crohn's disease activity index: r = -0.253) and with inflammatory parameters (C-reactive protein: r = 0.008; erythrocyte sedimentation rate: r = 0.012). CONCLUSIONS Since vitamin D deficiency can be frequently observed in Hungarian patients with inflammatory bowel disease, its level should be tested in these patients.
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Affiliation(s)
- Katalin Lőrinczy
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest Szentkirályi u. 46. 1088
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Targownik LE, Bernstein CN, Leslie WD. Inflammatory bowel disease and the risk of osteoporosis and fracture. Maturitas 2013; 76:315-9. [PMID: 24139749 DOI: 10.1016/j.maturitas.2013.09.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 09/19/2013] [Indexed: 12/11/2022]
Abstract
Inflammatory bowel disease (IBD) is commonly believed to increase the risk of bone mineral loss, leading to osteoporosis and an increased risk of disabling fractures. In this narrative review, we will presenting a summary of the published medical literature in regards to the relationship between IBD and the development of osteoporosis, bone mineral loss, and fractures. We will explore the epidemiology of metabolic bone disease in IBD, focusing on the prevalence and both the general and IBD-specific risk factors for the development of osteoporosis and of fracture in persons with IBD. We will also examine the role of the inflammatory process in IBD promoting excessive bone mineral loss, as well as the role that low body mass, corticosteroid use, diet, and nutrient malabsorption play in contributing to bone disease. Last, we will discuss our recommendation for: screening for osteoporosis in IBD patients, the use of preventative strategies, and therapeutic interventions for treating osteoporosis in persons with IBD.
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Affiliation(s)
- Laura E Targownik
- Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Radhakrishnan VM, Ramalingam R, Larmonier CB, Thurston RD, Laubitz D, Midura-Kiela MT, McFadden RMT, Kuro-O M, Kiela PR, Ghishan FK. Post-translational loss of renal TRPV5 calcium channel expression, Ca(2+) wasting, and bone loss in experimental colitis. Gastroenterology 2013; 145:613-24. [PMID: 23747339 PMCID: PMC3755094 DOI: 10.1053/j.gastro.2013.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 05/30/2013] [Accepted: 06/01/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS Dysregulated Ca(2+) homeostasis likely contributes to the etiology of inflammatory bowel disease-associated loss of bone mineral density. Experimental colitis leads to decreased expression of Klotho, a protein that supports renal Ca(2+) reabsorption by stabilizing the transient receptor potential vanilloid 5 (TRPV5) channel on the apical membrane of distal tubule epithelial cells. METHODS Colitis was induced in mice via administration of 2,4,6-trinitrobenzenesulfonic acid (TNBS) or transfer of CD4(+)interleukin-10(-/-) and CD4(+), CD45RB(hi) T cells. We investigated changes in bone metabolism, renal processing of Ca(2+), and expression of TRPV5. RESULTS Mice with colitis had normal serum levels of Ca(2+) and parathormone. Computed tomography analysis showed a decreased density of cortical and trabecular bone, and there was biochemical evidence for reduced bone formation and increased bone resorption. Increased fractional urinary excretion of Ca(2+) was accompanied by reduced levels of TRPV5 protein in distal convoluted tubules, with a concomitant increase in TRPV5 sialylation. In mouse renal intermedullary collecting duct epithelial (mIMCD3) cells transduced with TRPV5 adenovirus, the inflammatory cytokines tumor necrosis factor, interferon-γ, and interleukin-1β reduced levels of TRPV5 on the cell surface, leading to its degradation. Cytomix induced interaction between TRPV5 and UBR4 (Ubiquitin recoginition 4), an E3 ubiquitin ligase; knockdown of UBR4 with small interfering RNAs prevented cytomix-induced degradation of TRPV5. The effects of cytokines on TRPV5 were not observed in cells stably transfected with membrane-bound Klotho; TRPV5 expression was preserved when colitis was induced with TNBS in transgenic mice that overexpressed Klotho or in mice with T-cell transfer colitis injected with soluble recombinant Klotho. CONCLUSIONS After induction of colitis in mice via TNBS administration or T-cell transfer, tumor necrosis factor and interferon-γ reduced the expression and activity of Klotho, which otherwise would protect TRPV5 from hypersialylation and cytokine-induced TRPV5 endocytosis, UBR4-dependent ubiquitination, degradation, and urinary wasting of Ca(2+).
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Duru N, van der Goes MC, Jacobs JWG, Andrews T, Boers M, Buttgereit F, Caeyers N, Cutolo M, Halliday S, Da Silva JAP, Kirwan JR, Ray D, Rovensky J, Severijns G, Westhovens R, Bijlsma JWJ. EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2013; 72:1905-13. [PMID: 23873876 DOI: 10.1136/annrheumdis-2013-203249] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.
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Affiliation(s)
- N Duru
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, , Utrecht, The Netherlands
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Bakker SF, Dik VK, Witte BI, Lips P, Roos JC, Van Bodegraven AA. Increase in bone mineral density in strictly treated Crohn's disease patients with concomitant calcium and vitamin D supplementation. J Crohns Colitis 2013; 7:377-84. [PMID: 22749232 DOI: 10.1016/j.crohns.2012.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 05/01/2012] [Accepted: 06/02/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Decreased bone mineral density (BMD) is common in Crohn's disease (CD) patients. This paper reports on the prevalence of decreased BMD in a referral cohort study of CD-patients next to the change of BMD over time in relation with CD-associated clinical characteristics. METHODS 205 CD patients of a referral hospital were enrolled between January1998-January 2010 when measurement of BMD by dual X-ray absorptiometry (DXA) was available. Follow-up DXA scan was performed in subjects with known risk factors besides Crohn indicative for low BMD. Treatment of CD patients was according to a protocol which is comparable to the current (inter)national guidelines. In osteopenic patients, supplemental vitamin D (800 IU) and Calcium (500-1000 mg) were prescribed. RESULTS Mean BMD at baseline was 0.97 ± 0.16 gram/cm(2) in lumbar spine and 0.87 ± 0.12 gram/cm(2) in the total hip. At baseline, higher age and low Body Mass Index (BMI), were negatively correlated with BMD. Eighty-four patients underwent a second BMD assessment with a median interval period of 4 years (IQR 3-6). A mean annual increase of +0.76% (95%CI: -2.63%; +3.87%) in lumbar spine and +0.43% (95%CI: -2.65% ; +1.11%) in total hip was observed. CONCLUSIONS Higher age, male sex, low BMI, and a higher age at diagnosis of CD were associated with low BMD. Follow-up of BMD in CD patients showed a contraintuitive small increase of BMD at lumbar spine and total hip in CD patients only using supplemental vitamin D and calcium next to strict treatment of CD.
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Affiliation(s)
- Sjoerd F Bakker
- Department of Gastroenterology and Hepatology, VU University Medical Centre, PO Box 7057, The Netherlands.
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Hwang C, Ross V, Mahadevan U. Micronutrient deficiencies in inflammatory bowel disease: from A to zinc. Inflamm Bowel Dis 2012; 18:1961-81. [PMID: 22488830 DOI: 10.1002/ibd.22906] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 01/11/2012] [Indexed: 12/13/2022]
Abstract
Inflammatory bowel disease (IBD) has classically been associated with malnutrition and weight loss, although this has become less common with advances in treatment and greater proportions of patients attaining clinical remission. However, micronutrient deficiencies are still relatively common, particularly in CD patients with active small bowel disease and/or multiple resections. This is an updated literature review of the prevalence of major micronutrient deficiencies in IBD patients, focusing on those associated with important extraintestinal complications, including anemia (iron, folate, vitamin B12) bone disease (calcium, vitamin D, and possibly vitamin K), hypercoagulability (folate, vitamins B6, and B12), wound healing (zinc, vitamins A and C), and colorectal cancer risk (folate and possibly vitamin D and calcium).
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Affiliation(s)
- Caroline Hwang
- Division of Gastroenterology, University of California, San Francisco, California, USA
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30
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Lekamwasam S, Adachi JD, Agnusdei D, Bilezikian J, Boonen S, Borgström F, Cooper C, Diez Perez A, Eastell R, Hofbauer LC, Kanis JA, Langdahl BL, Lesnyak O, Lorenc R, McCloskey E, Messina OD, Napoli N, Obermayer-Pietsch B, Ralston SH, Sambrook PN, Silverman S, Sosa M, Stepan J, Suppan G, Wahl DA, Compston JE. A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. Osteoporos Int 2012; 23:2257-76. [PMID: 22434203 DOI: 10.1007/s00198-012-1958-1] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 02/13/2012] [Indexed: 01/13/2023]
Abstract
UNLABELLED This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer. INTRODUCTION The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010. METHODS AND RESULTS The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review. CONCLUSIONS Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.
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Affiliation(s)
- S Lekamwasam
- Department of Medicine, Faculty of Medicine, Centre for Metabolic Bone Diseases, Galle, Sri Lanka
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Smith MA, Smith T, Trebble TM. Nutritional management of adults with inflammatory bowel disease: practical lessons from the available evidence. Frontline Gastroenterol 2012; 3:172-179. [PMID: 28839660 PMCID: PMC5517270 DOI: 10.1136/flgastro-2011-100032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2012] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is associated with impairment of nutritional status both anthropometrically and biochemically, which results from both qualitative and quantitative changes in dietary intake alongside disease activity. Dietary intervention to replace deficiency is essential and may also be used to treat active disease and to reduce symptoms. The evidence for dietary interventions in this area is reviewed and the following recommendations made: ■Assessment of nutritional status is an essential part of the investigation of all patients with IBD and deficiency should be actively sought.■Any patient with macro- or micronutrient deficiency should be referred for dietetic assessment.■Micronutrient deficiency (most frequently iron, vitamin B12, folate and magnesium) should be replaced aggressively, parenterally if necessary.■Significant improvement in gastrointestinal symptoms can be achieved by low-residue diets (for stricturing disease) and (always under dietetic supervision) management of lactose and other intolerances.■Irritable bowel syndrome symptoms in patients with IBD can respond to low fermentable oligo-, di-, monosaccharide and polyol (FODMAP) diets, again this must be done under dietetic supervision.■Active Crohn's disease can be treated by exclusive enteral nutrition (elemental/polymeric/altered fat formulations all have equivalent efficacy).■Enteral nutrition can maintain remission in Crohn's disease and in this context can be given alongside normal oral intake.■Nutritional support does not have an established role in the treatment of active ulcerative colitis, other than in the management of malnutrition.■Total parenteral nutrition should not be used unless intestinal failure occurs.■There is insufficient evidence to support the routine use of Ω3 fish oil, prebiotics and glutamine in the treatment of active IBD.
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Affiliation(s)
- Melissa A Smith
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Trevor Smith
- Department of Gastroenterology and Human Nutrition, Southampton University Hospitals Trust, Southampton General Hospital, Southampton, UK
| | - Timothy M Trebble
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Abstract
Long-term corticosteroid treatment is the most common secondary cause of bone loss. Patients treated with long-term corticosteroid therapy may develop osteopenia or osteoporosis, and many have fractures. It is difficult to predict which corticosteroid-treated patients will develop significant skeletal complications because of variability in the underlying diseases treated with corticosteroids, and because of variation in corticosteroid dose over time. Corticosteroid therapy causes an alteration in the ratio between osteoprotegerin (OPG) and receptor activator of nuclear factor κ B (RANK) ligand (RANKL), which leads to early increased bone resorption for the first 3-6 months, with long-term treatment leading primarily to suppression of bone formation. Recently published recommendations advise the use of bisphosphonates or teriparatide in high-risk patients, depending on fracture risk assessed by bone mineral density testing. This article gives an update of current knowledge regarding the pathophysiology, clinical presentation and evaluation, and prevention and treatment of patients with corticosteroid-induced osteoporosis.
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El-Hodhod MAA, Hamdy AM, Abbas AA, Moftah SG, Ramadan AAM. Fibroblast growth factor 23 contributes to diminished bone mineral density in childhood inflammatory bowel disease. BMC Gastroenterol 2012; 12:44. [PMID: 22551310 PMCID: PMC3438067 DOI: 10.1186/1471-230x-12-44] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 04/24/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diminished bone mineral density (BMD) is of significant concern in pediatric inflammatory bowel disease (IBD). Exact etiology is debatable. The recognition of fibroblast growth factor 23 (FGF23), a phosphaturic hormone related to tumor necrosis factor alpha (TNF-α) makes it plausible to hypothesize its possible relation to this pathology. METHODS In this follow up case control study, BMD as well as serum levels of FGF23, calcium, phosphorus, alkaline phosphatase, creatinine, parathyroid hormone, 25 hydroxy vitamin D3 and 1, 25 dihydroxy vitamin D3 were measured in 47 children with IBD during flare and reassessed in the next remission. RESULTS Low BMD was frequent during IBD flare (87.2%) with significant improvement after remission (44.7%). During disease flare, only 21.3% of patients had vitamin D deficiency, which was severe in 12.8%. During remission, all patients had normal vitamin D except for two patients with Crohn's disease (CD) who remained vitamin D deficient. Mean value of serum FGF23 was significantly higher among patients with IBD during flare compared to controls. It showed significant improvement during remission but not to the control values. 1, 25 dihydroxy vitamin D3, FGF23, serum calcium and urinary phosphorus were significant determinants of BMD in IBD patients. CONCLUSIONS We can conclude that diminished BMD in childhood IBD is a common multifactorial problem. Elevated FGF23 would be a novel addition to the list of factors affecting bone mineral density in this context. Further molecular studies are warranted to display the exact interplay of these factors.
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Narula N, Marshall JK. Management of inflammatory bowel disease with vitamin D: beyond bone health. J Crohns Colitis 2012; 6:397-404. [PMID: 22398052 DOI: 10.1016/j.crohns.2011.10.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/04/2011] [Accepted: 10/30/2011] [Indexed: 02/08/2023]
Abstract
A relationship between vitamin D and several disorders, including Crohn's disease (CD), has recently been proposed. Vitamin D appears to have several important actions beyond the maintenance of bone health, including various effects on the immune system. Vitamin D deficiency has been implicated in the development of CD, and its analogues may have a role in the treatment of CD. Current research also suggests a role for vitamin D in counteracting some IBD-specific complications, including osteopenia, colorectal neoplasia, and depression. There remains a need for prospective studies to further delineate these relationships. Given current evidence and the apparent safety of vitamin D supplementation, it appears reasonable to screen for and treat vitamin D deficiency in patients with IBD.
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Affiliation(s)
- Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Ismail MH, Al-Elq AH, Al-Jarodi ME, Azzam NA, Aljebreen AM, Al-Momen SA, Bseiso BF, Al-Mulhim FA, Alquorain A. Frequency of low bone mineral density in Saudi patients with inflammatory bowel disease. Saudi J Gastroenterol 2012; 18:201-7. [PMID: 22626800 PMCID: PMC3371423 DOI: 10.4103/1319-3767.96458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Metabolic bone disease is common in patients with inflammatory bowel disease (IBD). Our aim was to determine the frequency of bone loss among Saudi patients with IBD and possible contributing risk factors. SETTINGS AND DESIGN We retrospectively reviewed Saudi patients with IBD, between 18 and 70 years of age, who had bone mass density (BMD) determined by dual-energy X-ray absorptiometry scanning at one of three hospitals in the Kingdom of Saudi Arabia from 2001 to 2008. PATIENTS AND METHODS Case notes and BMDs results were carefully reviewed for demographic and clinical data. Low bone mass, osteopenia, and osteoporosis were defined according to the WHO guidelines. STATISTICAL ANALYSIS USED Predictive factors for BMD were analyzed using group comparisons and stepwise regression analyses. RESULTS Ninety-five patients were included; 46% had Crohn's disease (CD) and 54% had ulcerative colitis (UC). The average age was 30.9±11.6 years. Using T-scores, the frequency of osteopenia was 44.2%, and the frequency of osteoporosis was 30.5% at both lumbar spine and proximal femur. Only 25.3% of patients exhibited a BMD within the normal range. Our results revealed a positive correlation between the Z-score in both the lumbar spine and the proximal femur and body mass index (BMI) (P=0.042 and P=0.018, respectively). On regression analysis BMI, age, and calcium supplementation were found to be the most important independent predictors of BMD. CONCLUSIONS Saudi patients with IBD are at an increased risk of low BMD and the frequency of decreased BMD in Saudi patients with CD and UC were similar. BMI and age were the most important independent predictors of low BMD.
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Affiliation(s)
- Mona H. Ismail
- Division of Gastroenterology, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia,Address for correspondence: Dr. Mona H. Ismail, University of Dammam, College of Medicine, King Fahd Hospital of the University, Department of Internal Medicine, Division of Gastroenterology, P. O. Box 40149, Al-Khobar 31952, Saudi Arabia. E-mail:
| | - Abdulmohsen H. Al-Elq
- Department of Endocrinology, Departments of Internal Medicine, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia
| | - Mahdi E. Al-Jarodi
- Department of Gastroenterology, Dammam Medical Complex, Kingdom of Saudi Arabia
| | - Nahla A. Azzam
- Department of Gastroenterology, King Khalid University Hospital-Riyadh, Kingdom of Saudi Arabia
| | | | - Sami A. Al-Momen
- Department of Gastroenterology, King Fahd Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Bahaa F. Bseiso
- Department of Gastroenterology, King Fahd Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Fatma A. Al-Mulhim
- Department of Radiology, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia
| | - Abdulaziz Alquorain
- Division of Gastroenterology, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia
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36
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Galland L. Inflammatory Bowel Disease. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bjelakovic G, Gluud LL, Nikolova D, Whitfield K, Wetterslev J, Simonetti RG, Bjelakovic M, Gluud C. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev 2011:CD007470. [PMID: 21735411 DOI: 10.1002/14651858.cd007470.pub2] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The available evidence on vitamin D and mortality is inconclusive. OBJECTIVES To assess the beneficial and harmful effects of vitamin D for prevention of mortality in adults. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science (to January 2011). We scanned bibliographies of relevant publications and asked experts and pharmaceutical companies for additional trials. SELECTION CRITERIA We included randomised trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention. Vitamin D could have been administered as supplemental vitamin D (vitamin D(3) (cholecalciferol) or vitamin D(2) (ergocalciferol)) or an active form of vitamin D (1α-hydroxyvitamin D (alfacalcidol) or 1,25-dihydroxyvitamin D (calcitriol)). DATA COLLECTION AND ANALYSIS Six authors extracted data independently. Random-effects and fixed-effect model meta-analyses were conducted. For dichotomous outcomes, we calculated the risk ratios (RR). To account for trials with zero events, meta-analyses of dichotomous data were repeated using risk differences (RD) and empirical continuity corrections. Risk of bias was considered in order to minimise risk of systematic errors. Trial sequential analyses were conducted to minimise the risk of random errors. MAIN RESULTS Fifty randomised trials with 94,148 participants provided data for the mortality analyses. Most trials included elderly women (older than 70 years). Vitamin D was administered for a median of two years. More than one half of the trials had a low risk of bias. Overall, vitamin D decreased mortality (RR 0.97, 95% confidence interval (CI) 0.94 to 1.00, I(2) = 0%). When the different forms of vitamin D were assessed separately, only vitamin D(3) decreased mortality significantly (RR 0.94, 95% CI 0.91 to 0.98, I(2) = 0%; 74,789 participants, 32 trials) whereas vitamin D(2), alfacalcidol, or calcitriol did not. Trial sequential analysis supported our finding regarding vitamin D(3), corresponding to 161 individuals treated to prevent one additional death. Vitamin D(3) combined with calcium increased the risk of nephrolithiasis (RR 1.17, 95% CI 1.02 to 1.34, I(2) = 0%). Alfacalcidol and calcitriol increased the risk of hypercalcaemia (RR 3.18, 95% CI 1.17 to 8.68, I(2) = 17%). Data on health-related quality of life and health economics were inconclusive. AUTHORS' CONCLUSIONS Vitamin D in the form of vitamin D(3) seems to decrease mortality in predominantly elderly women who are mainly in institutions and dependent care. Vitamin D(2), alfacalcidol, and calcitriol had no statistically significant effect on mortality. Vitamin D(3) combined with calcium significantly increased nephrolithiasis. Both alfacalcidol and calcitriol significantly increased hypercalcaemia.
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Affiliation(s)
- Goran Bjelakovic
- Department of Internal Medicine - Gastroenterology and Hepatology, Medical Faculty, University of Nis, Zorana Djindjica 81, Nis, Serbia, 18000
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Ghishan FK, Kiela PR. Advances in the understanding of mineral and bone metabolism in inflammatory bowel diseases. Am J Physiol Gastrointest Liver Physiol 2011; 300:G191-201. [PMID: 21088237 PMCID: PMC3043650 DOI: 10.1152/ajpgi.00496.2010] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 11/11/2010] [Indexed: 02/08/2023]
Abstract
Chronic inflammatory disorders such as inflammatory bowel diseases (IBDs) affect bone metabolism and are frequently associated with the presence of osteopenia, osteoporosis, and increased risk of fractures. Although several mechanisms may contribute to skeletal abnormalities in IBD patients, inflammation and inflammatory mediators such as TNF, IL-1β, and IL-6 may be the most critical. It is not clear whether the changes in bone metabolism leading to decreased mineral density are the result of decreased bone formation, increased bone resorption, or both, with varying results reported in experimental models of IBD and in pediatric and adult IBD patients. New data, including our own, challenge the conventional views, and contributes to the unraveling of an increasingly complex network of interactions leading to the inflammation-associated bone loss. Since nutritional interventions (dietary calcium and vitamin D supplementation) are of limited efficacy in IBD patients, understanding the pathophysiology of osteopenia and osteoporosis in Crohn's disease and ulcerative colitis is critical for the correct choice of available treatments or the development of new targeted therapies. In this review, we discuss current concepts explaining the effects of inflammation, inflammatory mediators and their signaling effectors on calcium and phosphate homeostasis, osteoblast and osteoclast function, and the potential limitations of vitamin D used as an immunomodulator and anabolic hormone in IBD.
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Affiliation(s)
- Fayez K Ghishan
- Dept. of Pediatrics, Steele Children's Research Center, Univ. of Arizona Health Sciences Center; 1501 N. Campbell Ave., Tucson, AZ 85724, USA
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Miheller P, Lőrinczy K, Lakatos PL. Clinical relevance of changes in bone metabolism in inflammatory bowel disease. World J Gastroenterol 2010; 16:5536-42. [PMID: 21105186 PMCID: PMC2992671 DOI: 10.3748/wjg.v16.i44.5536] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Low bone mineral density is an established, frequent, but often neglected complication in patients with inflammatory bowel disease (IBD). Data regarding the diagnosis, therapy and follow-up of low bone mass in IBD has been partially extrapolated from postmenopausal osteoporosis; however, the pathophysiology of bone loss is altered in young patients with IBD. Fracture, a disabling complication, is the most important clinical outcome of low bone mass. Estimation of fracture risk in IBD is difficult. Numerous risk factors have to be considered, and these factors should be weighed properly to help in the identification of the appropriate patients for screening. In this editorial, the authors aim to highlight the most important clinical aspects of the epidemiology, prevention, diagnosis and treatment of IBD-related bone loss.
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Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, Curtis JR, Furst DE, McMahon M, Patkar NM, Volkmann E, Saag KG. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken) 2010; 62:1515-26. [PMID: 20662044 DOI: 10.1002/acr.20295] [Citation(s) in RCA: 478] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 07/06/2010] [Indexed: 12/25/2022]
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Laird E, Ward M, McSorley E, Strain JJ, Wallace J. Vitamin D and bone health: potential mechanisms. Nutrients 2010; 2:693-724. [PMID: 22254049 PMCID: PMC3257679 DOI: 10.3390/nu2070693] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 06/22/2010] [Accepted: 06/29/2010] [Indexed: 12/31/2022] Open
Abstract
Osteoporosis is associated with increased morbidity, mortality and significant economic and health costs. Vitamin D is a secosteriod hormone essential for calcium absorption and bone mineralization which is positively associated with bone mineral density [BMD]. It is well-established that prolonged and severe vitamin D deficiency leads to rickets in children and osteomalacia in adults. Sub-optimal vitamin D status has been reported in many populations but it is a particular concern in older people; thus there is clearly a need for effective strategies to optimise bone health. A number of recent studies have suggested that the role of vitamin D in preventing fractures may be via its mediating effects on muscle function (a defect in muscle function is one of the classical signs of rickets) and inflammation. Studies have demonstrated that vitamin D supplementation can improve muscle strength which in turn contributes to a decrease in incidence of falls, one of the largest contributors to fracture incidence. Osteoporosis is often considered to be an inflammatory condition and pro-inflammatory cytokines have been associated with increased bone metabolism. The immunoregulatory mechanisms of vitamin D may thus modulate the effect of these cytokines on bone health and subsequent fracture risk. Vitamin D, therefore, may influence fracture risk via a number of different mechanisms.
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Affiliation(s)
- Eamon Laird
- School of Biomedical Sciences, University of Ulster, Coleraine, UK.
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Kitazaki S, Mitsuyama K, Masuda J, Harada K, Yamasaki H, Kuwaki K, Takedatsu H, Sugiyama G, Tsuruta O, Sata M. Clinical trial: comparison of alendronate and alfacalcidol in glucocorticoid-associated osteoporosis in patients with ulcerative colitis. Aliment Pharmacol Ther 2009; 29:424-30. [PMID: 19035979 DOI: 10.1111/j.1365-2036.2008.03899.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bone loss is often observed in patients with ulcerative colitis, particularly if they require glucocorticoids. AIM To determine whether the bisphosphonate, alendronate, is safe and effective in preserving bone mass compared to the active vitamin D3, alfacalcidol, in ulcerative colitis patients receiving glucocorticoids. METHODS Thirty-nine patients with ulcerative colitis and treated with glucocorticoids were randomized to receive alendronate (5 mg/day) or alfacalcidol (1 microg/day) daily for 12 months. Loss of bone mass was evaluated by bone mineral density, bone resorption by urinary N-telopeptide for type I collagen, and bone formation by serum bone alkaline phosphatase. RESULTS Alendronate, but not alfacalcidol, significantly increased bone mineral density in the lumbar spine. Alendronate decreased serum bone alkaline phosphatase levels, but alfacalcidol did not. Urinary N-telopeptide for type I collagen levels decreased in both groups, but were significantly lower in the alendronate group. There were no significant differences in the adverse events in the two groups. CONCLUSION Our study indicates that alendronate is a safe, well-tolerated and more effective therapy than alfacalcidol for preventing glucocorticoid-associated bone loss in patients with ulcerative colitis.
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Affiliation(s)
- S Kitazaki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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Effectiveness of risedronate in osteoporotic postmenopausal women with inflammatory bowel disease. Menopause 2008; 15:730-6. [DOI: 10.1097/gme.0b013e318159f190] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Viswanathan A, Sylvester FA. Chronic pediatric inflammatory diseases: effects on bone. Rev Endocr Metab Disord 2008; 9:107-22. [PMID: 18165904 DOI: 10.1007/s11154-007-9070-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
In children, chronic inflammatory diseases present a significant challenge to long-term skeletal health. These conditions are often associated with poor appetite and suboptimal overall nutrition, altered nutrient utilization, delayed puberty, inactivity, and reduced muscle mass, all of which can alter bone metabolism. In addition, bone cell activity is susceptible to the effects of the immune response that characterizes these diseases. Moreover, drugs used to treat these maladies, notably glucocorticoids, may have negative effects on bone formation and on linear growth in developing children. As a result, predicted peak bone mass may not be achieved, and fracture risk may be increased in the short term or in the future. Studies using primarily dual energy X-ray absorptiometry have documented that deficits in bone mass are common in these diseases. However, there are wide variations in the prevalence of low bone mass, largely due to differences in the characteristics of each study population. Recent studies provide insight into the pathogenesis of decreased bone mass in these conditions. In this paper we will provide an overview of the effects of chronic inflammatory conditions on bone mass in children. We will also present relevant data from adult patients, when pediatric data are scant or not available.
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Abstract
Osteoporosis is a major public health problem, and as life expectancy and the world's population continue to increase will become even more important. Thus, there is an urgent need to develop and implement nutritional approaches and policies for the prevention and treatment of osteoporosis. Patients with some chronic inflammatory diseases appear to be more likely to develop osteopenia, and in some cases earlier in life, which is of particular concern as the incidence of inflammatory diseases in the Western world is increasing. While the cause of bone loss in patients with inflammatory disease is multifactorial, nutrition may have a role. Many of these patients may have one or more nutritional deficiencies, which can lead to altered rates of bone metabolism. On the other hand, some nutritional factors may attenuate the inflammatory process itself, and thus may indirectly benefit bone metabolism and bone health in patients with inflammatory disease. The present review will consider these issues, particularly in the context of inflammatory bowel disease, coeliac diease and atherosclerosis.
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Rodríguez-Bores L, Barahona-Garrido J, Yamamoto-Furusho JK. Basic and clinical aspects of osteoporosis in inflammatory bowel disease. World J Gastroenterol 2007; 13:6156-65. [PMID: 18069754 PMCID: PMC4171224 DOI: 10.3748/wjg.v13.i46.6156] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Low bone mineral density and the increased risk of fracture in gastrointestinal diseases have a multifactorial pathogenesis. Inflammatory bowel disease (IBD) has been associated with an increased risk of osteoporosis and osteopenia and epidemiologic studies have reported an increased prevalence of low bone mass in patients with IBD. Certainly, genetics play an important role, along with other factors such as systemic inflammation, malnutrition, hypogonadism, glucocorticoid therapy in IBD and other lifestyle factors. At a molecular level the proinflammatory cytokines that contribute to the intestinal immune response in IBD are known to enhance bone resorption. There are genes influencing osteoblast function and it is likely that LRP5 may be involved in the skeletal development. Also the identification of vitamin D receptors (VDRs) and some of its polymorphisms have led to consider the possible relationships between them and some autoimmune diseases and may be involved in the pathogenesis through the exertion of its immunomodulatory effects during inflammation. Trying to explain the physiopathology we have found that there is increasing evidence for the integration between systemic inflammation and bone loss likely mediated via receptor for activated nuclear factor kappa-B (RANK), RANK-ligand, and osteoprotegerin, proteins that can affect both osteoclastogenesis and T-cell activation. Although glucocorticoids can reduce mucosal and systemic inflammation, they have intrinsic qualities that negatively impact on bone mass. It is still controversial if all IBD patients should be screened, especially in patients with preexisting risk factors for bone disease. Available methods to measure BMD include single energy x-ray absorptiometry, DXA, quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. DXA is the establish method to determine BMD, and routinely is measured in the hip and the lumbar spine. There are several treatments options that have proven their effectiveness, while new emergent therapies such as calcitonin and teriparatide among others remain to be assessed.
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Aghdassi E, Wendland BE, Stapleton M, Raman M, Allard JP. Adequacy of nutritional intake in a Canadian population of patients with Crohn's disease. ACTA ACUST UNITED AC 2007; 107:1575-80. [PMID: 17761234 DOI: 10.1016/j.jada.2007.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Indexed: 12/12/2022]
Abstract
Crohn's disease is frequently associated with nutritional deficiencies, often a result of disease activity and poor oral intake. This study investigated the adequacy of dietary intake, based on the Canadian Dietary Reference Intake, in ambulatory patients with Crohn's disease and a normal body mass index (BMI; calculated as kg/m(2)). This was a cross-sectional study of 74 patients with mean age of 35.7+/-1.4 years and BMI of 23.05+/-0.45. All patients completed a 7-day food record and a diary for the Crohn's Disease Activity Index. Mean Crohn's Disease Activity Index was 138.99+/-11.38. Energy and protein intakes were within the recommended levels of intake, but total carbohydrates, fat, and saturated fat intake exceeded the recommended levels of <55%, <35%, and <10% in 39.2%, 27%, and 59.5% of the patients, respectively. Micronutrient intakes were suboptimal most notably for folate, vitamins C, E, and calcium. There were no substantial differences between patients with active and inactive disease in terms of failure to meet the Dietary Reference Intake. In conclusion, in this population sample, a large number of ambulatory patients with Crohn's disease have suboptimal dietary patterns despite a normal BMI and inactive disease. Dietary counseling and supplementation may be warranted in this patient population.
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Effect of calcium and vitamin D supplementation on bone mineral density in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2007; 45:538-45. [PMID: 18030230 DOI: 10.1097/mpg.0b013e3180dca0cc] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the effect of calcium and vitamin D2 supplementation on bone mineral density (BMD) in children with inflammatory bowel disease (IBD). PATIENTS AND METHODS This was an open-label, prospective study conducted over a 12-month period. Seventy-two patients were divided into 2 groups based on lumbar spine areal BMD (L2-4 aBMD). Patients with an L2-4 aBMD z score of -1 or higher were assigned to the control group (n = 33; mean age, 11.0 +/- 3.5 years; 20 boys). Patients with an L2-4 aBMD of less than -1 (n = 39; mean age 11.8 +/- 2.5 years; 25 boys) were allocated to the intervention group and received 1000 mg of supplemental elemental calcium daily for 12 months (n = 19) or supplemental calcium for 12 months and 50,000 IU of vitamin D2 monthly for 6 months (n = 20). RESULTS The 2 groups differed in L2-4 aBMD z scores (intervention, -1.9 +/- 0.6; control, -0.2 +/- 0.6; P < 0.001) and volumetric L2-4 BMD (vBMD; intervention, 0.29 +/- 0.04; control, 0.33 +/- 0.06; P < 0.001). After 1 year of therapy, the control and intervention groups had similar changes in height z scores, L2-4 aBMD, L2-4 vBMD (z score change, L2-4 aBMD: control 0.2 +/- 0.6 [n = 21], intervention 0.4 +/- 0.6; P = 0.4 [n = 26]; z score change, L2-4 vBMD: control 0.1 +/- 0.4, intervention 0.2 +/- 0.6; P = 0.74). The changes in these parameters were similar between patients who had received calcium only or calcium plus vitamin D. CONCLUSIONS These results suggest that, in children with IBD, supplementation of calcium and vitamin D does not accelerate accrual in L2-4 BMD.
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Roblin X, Phelip JM, Genevois M, Ducros V, Bonaz B. Hyperhomocysteinaemia is associated with osteoporosis in patients with Crohn's disease. Aliment Pharmacol Ther 2007; 25:797-804. [PMID: 17373918 DOI: 10.1111/j.1365-2036.2007.03260.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A high prevalence of osteoporosis is observed in Crohn's disease. Recent data have shown that homocysteinaemia is an important risk factor in low-bone mineralization and fracture. AIM To look for an association between homocysteinaemia and low-bone mineralization in Crohn's disease patients. PATIENTS AND METHODS Ninety-two consecutive patients (sex ratio M/F 0.87; mean age: 36.6 +/- 13.2 years) were recruited between 2003 and 2005. Bone densitometry was performed on inclusion. The following parameters were analysed: age, sex, Crohn's Disease Activity Index, duration and extent of Crohn's disease, smoking status, corticosteroid treatment, immunosuppressive drugs, plasma homocysteine, folate and vitamin B12 concentration. RESULTS The prevalence of a high homocysteine level (>15 micromol/L) was 60%. Osteoporosis and low-bone mineralization observed in 26 (28%), and 60 (65%) patients, respectively. On a multivariate analysis, associated factors for osteoporosis and low-bone mineralization were respectively: hyperhomocysteinaemia (OR: 61.4; CI: 95: 23-250; P < 0.001), and ileal Crohn's disease [OR: 13.8; CI: 95: 2.5-150; P = 0.036] for osteoporosis and hyperhomocysteinaemia [OR: 63.7; CI: 95: 8.5-250; P < 0.001] and disease duration of at least 5 years [OR: 11.4; CI: 95: 1.31-99; P = 0.039] for low-bone mineralization. Results were similar whichever site osteoporosis was detected. CONCLUSION Hyperhomocysteinaemia was observed in 60% of our Crohn's disease patients and was strongly associated with low-bone mineralization and osteoporosis (OR: 61.4).
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Affiliation(s)
- X Roblin
- Department of Gastroenterology and Liver Diseases, CHU de Grenoble, Grenoble, France.
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Gilman J, Cashman KD. The effect of marine oil-derived n-3 fatty acids on transepithelial calcium transport in Caco-2 cell models of healthy and inflamed intestines. Br J Nutr 2007; 97:281-8. [PMID: 17298696 DOI: 10.1017/s0007114507201758] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Marine oil-derived n-3 fatty acids have been shown to stimulate intestinal Ca absorption in animal studies, but the effects of such fatty acids on Ca absorption in human subjects are relatively unknown. In particular, n-3 fatty acids may be of therapeutic value for some Crohn's disease patients who experience Ca malabsorption. Therefore, the aim of the present study was to investigate the effect of 20 : 5n-3 and 22 : 6n-3 on transepithelial Ca transport across monolayers of healthy Caco-2 cells as well as of TNF-α-treated Caco-2 cells (an in vitro model of Crohn's disease). Caco-2 cells were seeded onto permeable filter supports and allowed to differentiate into monolayers, which were treated with 80 μm-20 : 5n-3, 80 μm-22 : 6n-3, or 40 μm-20 : 5n-3+40 μm-22 : 6n-3 for 6 or 8 d, with or without co-treatment with TNF-α (10 ng/ml) (n 11–15 monolayers per treatment). On day 16, transepithelial and transcellular transport of 45Ca and fluorescein transport (a marker of paracellular diffusion) were measured. Treatment of healthy and inflamed Caco-2 cells with 20 : 5n-3, 22 : 6n-3 and both fatty acids combined for 8 d significantly (P < 0·005–0·01) increased total transepithelial Ca transport compared with that in control, effects which were mediated by an enhanced rate of transcellular Ca transport. The effects of n-3 fatty acids on Ca absorption after 6 d were less clear-cut. In conclusion, the present in vitro findings highlight the need to investigate the effect of marine oil-based n-3 fatty acids on Ca absorption in vivo in studies of healthy human subjects as well as of Crohn's disease patients.
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Affiliation(s)
- Jennifer Gilman
- Department of Food and Nutritional Sciences, University College, Cork, Republic of Ireland
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