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Risk Factors for Worsening of Bone Loss in Patients Newly Diagnosed with Inflammatory Bowel Disease. Gastroenterol Res Pract 2022; 2022:1498293. [PMID: 35419052 PMCID: PMC9001094 DOI: 10.1155/2022/1498293] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Bone loss is common in patients with inflammatory bowel disease (IBD). The aim of the present study was to determine the prevalence of metabolic bone disease in patients newly diagnosed with IBD and to identify the risk factors for bone loss over time. Methods. We performed a retrospective, both cross-sectional and longitudinal, study to extract the risk factors of bone loss (including osteopenia and osteoporosis) in patients newly diagnosed with IBD, using dual-energy X-ray absorptiometry (DXA). Results. A total of 639 patients newly diagnosed with IBD that had at least one DXA were included in the cross-sectional study. Osteopenia and osteoporosis were diagnosed in 24.6% and 5.4% of patients, respectively. Age at diagnosis, body mass index, and serum phosphorus were identified as independent factors associated with bone loss at baseline. A total of 380 of the 639 IBD patients (including 212 CD patients and 168 UC patients) with at least a second DXA scan were included in the longitudinal study. 42.6% of the patients presented a worsening of bone loss in the follow-up study. Menopause, albumin, and use of corticosteroids were identified as independent factors associated with worsening of bone loss. Conclusions. Metabolic bone disease is common in IBD patients, and there is a significant increase in prevalence of bone loss over time. Postmenopausal female, malnourished patients, and those requiring corticosteroid treatment are at risk for persistent bone loss. Therefore, BMD measurements and early intervention with supplementation of calcium and vitamin D are recommended in IBD patients with high-risk factors.
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Moran MM, Wessman P, Rolfson O, Bohl DD, Kärrholm J, Keshavarzian A, Sumner DR. The risk of revision following total hip arthroplasty in patients with inflammatory bowel disease, a registry based study. PLoS One 2021; 16:e0257310. [PMID: 34735461 PMCID: PMC8568118 DOI: 10.1371/journal.pone.0257310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the intestinal tract and is associated with decreased bone mineral density. IBD patients are at higher risk of osteopenia, osteoporosis and fracture compared to non-IBD patients. The impact of IBD on the performance of orthopedic implants has not been well studied. We hypothesized that a history of IBD at the time of primary total hip arthroplasty (THA) would increase the risk of subsequent failure as assessed by revision surgery. A retrospective implant survival analysis was completed using the Swedish Hip Arthroplasty Registry and the Sweden National Patient Register. A total of 150,073 patients undergoing THA for osteoarthritis within an 18-year period were included in the study. THA patients with (n = 2,604) and without (n = 147,469) a history of IBD at the time of THA were compared with primary revision as the main endpoint and adjusted using sex, age category and comorbidity (Elixhauser scores) as covariates. We found that patients with a history of IBD had a relatively higher risk of revision surgery for septic causes while the non-IBD patients had a relatively higher risk of revision for aseptic causes (p = 0.004). Our findings suggest there may be an association between gut health and THA performance.
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Affiliation(s)
- Meghan M. Moran
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Peter Wessman
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel D. Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States of America
| | - Johan Kärrholm
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ali Keshavarzian
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Rush Medical College, Chicago, IL, United States of America
| | - D. Rick Sumner
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States of America
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Lee JS, Lee HS, Jang BI, Kim ES, Kim SK, Kim KO, Lee YJ, Lee HJ, Kim EY, Jung YJ, Yang CH. Low Bone Mineral Density in Young Patients Newly Diagnosed with Inflammatory Bowel Disease. Dig Dis Sci 2021; 66:605-611. [PMID: 32222926 DOI: 10.1007/s10620-020-06220-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 03/18/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND The prevalence and risk factors of low bone mineral density (BMD) in Asian patients newly diagnosed with inflammatory bowel disease (IBD) have not been fully suggested. AIMS We aimed to examine the prevalence and risk factors of low BMD in young Korean patients newly diagnosed with IBD. METHODS We prospectively enrolled 132 patients aged less than 50 years and newly diagnosed with IBD from six tertiary referral centers in Korea between November 2014 and April 2017. BMD was measured by dual-energy X-ray absorptiometry, and then the Z-score was determined. We defined low BMD as a Z-score ≤ - 1.0. RESULTS Of 68 patients with ulcerative colitis (UC), 22 (32.4%) had low BMD. Also, of 64 patients with Crohn's disease (CD), 24 (37.5%) showed low BMD. Results from multivariate regression analysis identified the risk factors for low BMD as a high level of alkaline phosphatase (ALP) (≥ 140 U/L) (P = 0.010) in UC patients, and being underweight (body mass index ≤ 18.5 kg/m2) (P = 0.017) in CD patients. CONCLUSIONS Our study showed that about one-third of newly diagnosed IBD Asian patients had low BMD. The clinical factors associated with low BMD were a high level of ALP in UC patients, and being underweight, in CD patients. Therefore, measurements of BMD in young patients should be considered at the diagnosis of IBD.
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Affiliation(s)
- Joon Seop Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hokuk-ro, Buk-gu, Daegu, 41404, Korea
| | - Hyun Seok Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hokuk-ro, Buk-gu, Daegu, 41404, Korea.
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hokuk-ro, Buk-gu, Daegu, 41404, Korea
| | - Sung Kook Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hokuk-ro, Buk-gu, Daegu, 41404, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Jik Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Yun Jin Jung
- Department of Internal Medicine, Fatima Hospital of Daegu, Daegu, Korea
| | - Chang Heon Yang
- Department of Internal Medicine, Dongguk University School of Medicine, Gyeongju, Korea
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Chedid VG, Kane SV. Bone Health in Patients With Inflammatory Bowel Diseases. J Clin Densitom 2020; 23:182-189. [PMID: 31375349 DOI: 10.1016/j.jocd.2019.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 12/19/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory medical condition with relapses and remission. Metabolic bone disease, including osteoporosis, is associated with IBD and imparts a significant morbidity if pathologic fractures were to occur. There has been a significant amount of research that evaluated the pathophysiology and associations between IBD and osteoporosis. Although corticosteroids contribute to the risk of low bone mineral density, osteoporosis and fractures, older age, female gender, smoking, and family history of fracture have been shown to contribute. Additionally, intestinal inflammation affects bone resorption and formation through proinflammatory cytokines such as tumor necrosis factor-a, interleukin-1, and interleukin-6 further accelerating bone loss. Little information is available on standardizing screening or treatment. It is important to recognize the risk factors that are associated with IBD and osteoporosis to identify the patient population at risk and initiate treatment/prevention strategies early. Treatment can include calcium, vitamin D, or bisphosphonates. Some studies showed benefit of treating the underlying IBD to improve bone mineral density.
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Affiliation(s)
- Victor G Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA.
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Do Patients Older Than 60 Years With Inflammatory Bowel Disease Have More Vertebral Fractures Than Age-matched Controls? A Study Using Abdominal and Pelvic CT Scans With Sagittal Reformatting as Screening Tool. J Am Acad Orthop Surg 2020; 28:214-219. [PMID: 31842063 DOI: 10.5435/jaaos-d-19-00440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION It is undetermined whether patients with inflammatory bowel diseases (IBDs) have increased prevalence of vertebral compression fractures (VCFs) since many VCFs are asymptomatic and radiographs may overlook them. We compared the prevalence of VCFs in patients older than 60 years with and without IBDs. METHODS We studied 55 patients with IBDs and 165 controls who underwent CT scans for nonspinal conditions. We evaluated the presence of VCFs, fracture severity using the Genant score, and we determined whether age, sex, diagnosis of IBD, treatment, and time since diagnosis were associated with VCFs. Using logistic regression analysis, we assessed the independent effect of each variable. RESULTS Mean age was 72.7 years; 165 patients (75%) were women. Thirty-five patients (16%) had at least one VCF (16.4% IBD; 15.8% controls, P = 0.92); both groups exhibited similar fracture severity. Patients with VCFs were older than patients without VCFs (79.8 versus 70.2, P < 0.01 IBD; 76.4 versus 72.4, P = 0.02 controls). No other clinical variables were different in patients with and without VCFs in either cohort. Only age was independently associated with VCFs in both cohorts. DISCUSSION VCFs were not more frequent or severe in patients older than 60 years with IBD presented than in age-matched controls.
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6
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Valero C, García MJ. Bone Metabolism in Inflammatory Bowel Disease and Celiac Disease. Clin Rev Bone Miner Metab 2019. [DOI: 10.1007/s12018-019-09269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hidalgo DF, Boonpheng B, Phemister J, Hidalgo J, Young M. Inflammatory Bowel Disease and Risk of Osteoporotic Fractures: A Meta-Analysis. Cureus 2019; 11:e5810. [PMID: 31720198 PMCID: PMC6823062 DOI: 10.7759/cureus.5810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Introduction Inflammatory bowel disease (IBD) and its complications have been well-established. The literature shows an association between IBD and decreased bone mineral density in the adult population. However, most studies have reported an association between IBD and osteoporosis, while the risk of fractures has not been well-studied. The aim of this meta-analysis is to summarize the best available evidence regarding IBS and osteoporotic fractures. Methods A review of the literature using the MEDLINE and EMBASE databases was performed during November 2017. We included cross-sectional and cohort studies that reported the relative risks, odds ratios, and hazard ratios comparing the risk of developing osteoporotic fractures among patients with IBD patients, both ulcerative colitis (UC) and Crohn's disease (CD), versus patients without IBD as controls. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using the generic inverse-variance method. Results After a review of the literature, seven studies fulfilled the eligibility criteria established during the analysis. A significant association was found between IBD and osteoporosis, with a pooled OR of 1.32 (95% CI, 1.2 - 1.4). Low heterogeneity among the studies was found, I2=42.3. No publication bias was found using the Egger regression test p=0.18. Sensitivity analysis showed that the inclusion of data on children by Kappelman et al. (2007) did not change the results. Conclusion A significant association between IBD and the risk of developing osteoporotic fractures was observed in this study. There is a 32% increased risk, which is consistent with different cohort studies previously done.
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Affiliation(s)
- Diego F Hidalgo
- Geriatrics, Jackson Memorial Hospital / University of Miami, Miami, USA
| | | | | | - Jessica Hidalgo
- Internal Medicine, San Francisco De Quito University, Quito, ECU
| | - Mark Young
- Gastroenterology, East Tennessee State University, Johnson City, USA
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Krela-Kaźmierczak I, Skrzypczak-Zielińska M, Kaczmarek-Ryś M, Michalak M, Szymczak-Tomczak A, Hryhorowicz ST, Szalata M, Łykowska-Szuber L, Eder P, Stawczyk-Eder K, Tomczak M, Słomski R, Dobrowolska A. ESR1 Gene Variants Are Predictive of Osteoporosis in Female Patients with Crohn's Disease. J Clin Med 2019; 8:jcm8091306. [PMID: 31450614 PMCID: PMC6780775 DOI: 10.3390/jcm8091306] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 01/07/2023] Open
Abstract
Decreased bone mass in patients with inflammatory bowel diseases (IBD) is a clinical problem with extremely severe consequences of osteoporotic fractures. Despite its increasing prevalence and the need for mandatory intervention and monitoring, it is often ignored in IBD patients’ care. Determining the biomarkers of susceptibility to bone mineral density disorder in IBD patients appears to be indispensable. We aim to investigate the impact of estrogen receptor gene (ESR1) gene polymorphisms on bone mineral density (BMD) in patients with ulcerative colitis (UC) and Crohn’s disease (CD), as they may contribute both, to osteoporosis and inflammatory processes. We characterised 197 patients with IBD (97 with UC, 100 with CD), and 41 controls carrying out vitamin D, calcium and phosphorus serum levels, and bone mineral density assessment at the lumbar spine and the femoral neck by dual-energy X-ray absorptiometry (DXA), ESR1 genotyping and haplotype analysis. We observed that women with CD showed the lowest bone density parameters, which corresponded to the ESR1 c.454-397T and c.454-351A allele dose. The ESR1 gene PvuII and XbaI TA (px) haplotype correlated with decreased femoral neck T-score (OR = 2.75, CI = [1.21–6.27], P-value = 0.016) and may be predictive of osteoporosis in female patients with CD.
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Affiliation(s)
- Iwona Krela-Kaźmierczak
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | | | - Marta Kaczmarek-Ryś
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszyńska 32, 60-479 Poznań, Poland.
| | - Michał Michalak
- Department of Computer Sciences and Statistics, Poznan University of Medical Sciences, Rokietnicka 7, 60-806 Poznań, Poland
| | - Aleksandra Szymczak-Tomczak
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Szymon T Hryhorowicz
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszyńska 32, 60-479 Poznań, Poland
| | - Marlena Szalata
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-637 Poznań, Poland
| | - Liliana Łykowska-Szuber
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Piotr Eder
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Kamila Stawczyk-Eder
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
| | - Maciej Tomczak
- Department of Psychology, Poznan University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
| | - Ryszard Słomski
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszyńska 32, 60-479 Poznań, Poland
- Department of Biochemistry and Biotechnology, Poznan University of Life Sciences, Dojazd 11, 60-637 Poznań, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Human Nutrition and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355 Poznań, Poland
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9
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Abstract
BACKGROUND Studies assessing the risk of fractures in inflammatory bowel diseases (IBD) have shown controversial results. GOALS We performed a systematic review and meta-analysis to assess the risk of fractures in IBD. STUDY Electronic databases were searched for cohort studies assessing the risk of fractures in IBD. The outcomes were the risk of overall fractures and at specific sites, and the association between the risk of fractures and the proportion of patients with corticosteroid use or osteoporosis. RESULTS Ten studies including 470,541 patients were identified. The risk of overall fractures in IBD patients was similar to controls [odds ratio (OR), 1.08; P=0.70; 95% confidence interval (CI), 0.72-1.62) with moderate heterogeneity (I=74.4%) which appeared to be due to the variable power and outcomes among the studies. The OR of fractures at the spine was significantly elevated at 2.21 (P<0.0001; 95% CI, 1.39-3.50) with low heterogeneity (I=26.1%). Meta-regression showed a correlation with the proportion of patients with steroid use. Risks of fractures at other sites (hip, rib, and wrist) were not elevated. Patients with fractures were more commonly on steroids compared with those without fractures (OR, 1.47; P=0.057; 95% CI, 0.99-2.20; I<0.0001%), but there was no correlation with osteoporosis. CONCLUSIONS IBD patients had no increased risk of overall fractures, but were at significantly increased risk of fractures at the spine, which was associated with steroid use. Strict surveillance and prevention of spine fractures are indicated in patients with IBD.
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10
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Kim D, Taleban S. A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population. Drugs Aging 2019; 36:607-624. [PMID: 31055789 DOI: 10.1007/s40266-019-00672-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.
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Affiliation(s)
- David Kim
- Division of Gastroenterology and Hepatology, Banner University Medical Center, Tucson, AZ, USA.,Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA
| | - Sasha Taleban
- Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA. .,Arizona Center on Aging, University of Arizona, Tucson, AZ, USA.
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11
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Maldonado-Pérez MB, Castro-Laria L, Caunedo-Álvarez A, Montoya-García MJ, Giner-García M, Argüelles-Arias F, Romero-Gómez M, Vázquez-Gámez MÁ. Does the Antitumor Necrosis Factor-α Therapy Decrease the Vertebral Fractures Occurrence in Inflammatory Bowel Disease? J Clin Densitom 2019; 22:195-202. [PMID: 30205986 DOI: 10.1016/j.jocd.2018.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/20/2018] [Accepted: 07/24/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND/OBJECTIVE Osteoporosis and osteoporotic fracture risk are extraintestinal manifestations of the inflammatory bowel disease, whose etiopathogenic mechanisms have not been determined yet. Anti-tumor necrosis factor (TNF)-α are used in treatment of inflammatory bowel disease (IBD), but it is unknown if they play a role in osteoporotic fracture prevention. The objective of this study was to know if anti-TNF decreases fracture risk or modifies bone mineral density. To determine the possible risk factors associated with fractures, and assess the incidence of vertebral fractures in IBD patients. METHODS Longitudinal prospective cohort study (7 yr of follow-up); which included 71 IBD patients, 23 received anti-TNF-α; the remaining 48 received conventional treatment, constituted the control group. Patients participated in a questionnaire which gathered risk factors associated with the development of osteoporosis and fractures. Radiographs of the dorsolumbar-spine were performed and also a bone density measurement. Their biochemical and bone remodeling parameters were determined. RESULTS Although patients who did not receive anti-TNF-α, suffered more fractures but biologic therapy did not reduce the risk of new vertebral fractures. The increase of bone mass was significantly higher the group treated with anti-TNF-α. The increase in the lumbar spine was of 8% and in the femoral neck was of 6.7%. The only determinant factor for the incidence of vertebral fractures was a history of previous fractures (odds ratio of 12.8; confidence interval 95% 2.37-69.9; p = 0.003). The incidence of vertebral fractures in IBD patients was considerably high: 26.7/700 patient-yr. CONCLUSIONS Anti-TNF-α, although increased bone mass in these patients, did not reduce the risk of new vertebral fractures. In this study, patients with IBD have a considerably high incidence of fractures. Only the existence of previous vertebral fractures was a predictive factor for consistent fractures.
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Affiliation(s)
- M B Maldonado-Pérez
- Department of Gastroenterology, University Hospital Virgen Macarena, Seville, Spain.
| | - L Castro-Laria
- Department of Gastroenterology, University Hospital Virgen Macarena, Seville, Spain
| | - A Caunedo-Álvarez
- Department of Gastroenterology, University Hospital Virgen Macarena, Seville, Spain; Medicine Department, University of Seville, Seville, Spain
| | - M J Montoya-García
- Medicine Department, University of Seville, Seville, Spain; Bone Metabolism Unit, University Hospital Virgen Macarena, Seville, Spain
| | - M Giner-García
- Medicine Department, University of Seville, Seville, Spain; Bone Metabolism Unit, University Hospital Virgen Macarena, Seville, Spain
| | - F Argüelles-Arias
- Department of Gastroenterology, University Hospital Virgen Macarena, Seville, Spain; Medicine Department, University of Seville, Seville, Spain
| | - M Romero-Gómez
- Department of Gastroenterology, University Hospital Virgen Macarena, Seville, Spain; Medicine Department, University of Seville, Seville, Spain
| | - M Á Vázquez-Gámez
- Medicine Department, University of Seville, Seville, Spain; Bone Metabolism Unit, University Hospital Virgen Macarena, Seville, Spain
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Lightner AL, Cima R. Use of the Rochester Epidemiology Project for Clinical Research in Colon and Rectal Surgery. Clin Colon Rectal Surg 2019; 32:8-15. [PMID: 30647541 DOI: 10.1055/s-0038-1673349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Rochester Epidemiology Project (REP), a longitudinal population-based database, is the largest epidemiologic database in the world. Originally established at Mayo Clinic in Rochester, Minnesota, the REP has been instrumental in defining the natural history of disease states and the impact of treatment in a well-defined population. In the United States, the REP has made important contributions to the colon and rectal literature, largely because healthcare is fragmented with no unique identifier to longitudinally follow-up with a patient throughout the system over his or her lifespan. Investigation with the REP has provided insight to the economic burden associated with inflammatory bowel disease, the benefit of screening for colorectal cancer, and the natural history of Mekel's and diverticular disease. In addition to practice changing research, the REP can be used as a model for future linkage systems in the United States.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert Cima
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
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13
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Oh HJ, Ryu KH, Park BJ, Yoon BH. Osteoporosis and Osteoporotic Fractures in Gastrointestinal Disease. J Bone Metab 2018; 25:213-217. [PMID: 30574465 PMCID: PMC6288610 DOI: 10.11005/jbm.2018.25.4.213] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 01/28/2023] Open
Abstract
Patients with gastrointestinal disease (GI) are at risk for osteopenia or osteoporosis, which can lead to fractures. Although these patients may be at risk from a young age, gastroenterologists often overlook this fact in practice. There are well-known GI diseases associated with osteopenia and osteoporosis, such as the post-gastrectomy state, inflammatory bowel disease (IBD), and celiac disease. As there is an increase in the prevalence of IBD patients, newly diagnosed celiac disease in adulthood, and gastric cancer survivors following gastrectomy, bone disease in these patients becomes an important issue. Here, we have discussed osteoporosis and fractures in GI disease, especially in the post-gastrectomy state, IBD, and celiac disease. Although the pathogenesis of bone loss in each disease has not been fully identified, we have confirmed that the prevalence of osteoporosis and fractures in each of these diseases is high. There are scarce studies comparing the prevalence of osteoporosis or osteoporotic fractures in GI disease patients with studies in postmenopausal women, and specific guidelines for their management in each disease have not been established. Intensive surveillance and management are needed to ensure that these patients attain peak bone mass for age and sex to prevent fractures.
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Affiliation(s)
- Hyun Jin Oh
- Division of Gastroenterology, Department of Internal Medicine, Center for Cancer Prevention and Detection, National Cancer Center, Goyang, Korea
| | - Kum Hei Ryu
- Division of Gastroenterology, Department of Internal Medicine, Center for Cancer Prevention and Detection, National Cancer Center, Goyang, Korea
| | - Bum Joon Park
- Division of Gastroenterology, Department of Internal Medicine, Center for Cancer Prevention and Detection, National Cancer Center, Goyang, Korea
| | - Byung-Ho Yoon
- Department of Orthopaedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Szafors P, Che H, Barnetche T, Morel J, Gaujoux-Viala C, Combe B, Lukas C. Risk of fracture and low bone mineral density in adults with inflammatory bowel diseases. A systematic literature review with meta-analysis. Osteoporos Int 2018; 29:2389-2397. [PMID: 29909470 DOI: 10.1007/s00198-018-4586-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/22/2018] [Indexed: 12/20/2022]
Abstract
Inflammatory bowel diseases (IBDs) are associated with a decreased bone mineral density, but the impact on fractures is unknown. In our study, global risk of fracture is increased for patients with IBDs versus controls. This result will help to determine the appropriate assessment with early screening and management of osteoporosis. Inflammatory bowel diseases (IBDs), such as Crohn's disease (CD) and ulcerative colitis (UC), are associated with a decreased bone mineral density (BMD). However, the impact on fracture risk is unknown and data are contradictory across studies. In this systematic review and meta-analysis, we aimed to assess the risk of fracture and presence of low BMD in patients with IBDs compared to healthy controls. A systematic search of literature was conducted of MEDLINE, EMBASE, the Cochrane library and abstracts from appropriate scientific congresses. Studies were selected if they compared the incidence of fractures and/or BMD measurement by dual-energy X-ray absorptiometry in patients with IBDs and healthy sex- and age-matched controls. Data were extracted by two independent investigators. Meta-analysis was performed with the inverse variance approach to estimate pooled odds ratios (ORs) and risk ratios (RRs) with their 95% confidence intervals (CIs). Twenty-four studies met the inclusion criteria. On the basis of nine studies, global risk of fracture was increased for patients with IBDs versus controls (RR = 1.38, 95% CI 1.11-1.73; p = 0.005). Fracture risk with IBDs was significantly increased for vertebral fractures (OR = 2.26, 95% CI 1.04-4.90; p < 0.001), but not for any other site. The analysis of 16 studies evaluating BMD showed a significant decrease in mean BMD and Z-scores for IBD patients versus controls at all sites. In our meta-analysis, patients with IBDs have an increased risk of fractures, especially in the spine, and significant decreased BMD at all sites, which suggests the need for identifying high-risk individuals among this population.
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Affiliation(s)
- P Szafors
- Department of Rheumatology, Lapeyronie Hospital and University of Montpellier, Montpellier, France
| | - H Che
- Department of Rheumatology, Lapeyronie Hospital and University of Montpellier, Montpellier, France
| | - T Barnetche
- Department of Rheumatology, Lapeyronie Hospital and EA2415, University of Montpellier, Montpellier, France
| | - J Morel
- Department of Rheumatology, Lapeyronie Hospital and University of Montpellier, Montpellier, France
| | - C Gaujoux-Viala
- Department of Rheumatology, FHU ACRONIM, Pellegrin University Hospital, Bordeaux, France
| | - B Combe
- Department of Rheumatology, Lapeyronie Hospital and University of Montpellier, Montpellier, France
| | - C Lukas
- Department of Rheumatology, Nîmes University Hospital and EA2415, University of Montpellier, Nimes, France.
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15
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Sylvester FA. Inflammatory Bowel Disease: Effects on Bone and Mechanisms. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1033:133-150. [PMID: 29101654 DOI: 10.1007/978-3-319-66653-2_7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inflammatory bowel disease (IBD) is associated with decreased bone mass and alterations in bone geometry from the time of diagnosis, before anti-inflammatory therapy is instituted. Deficits in bone mass can persist despite absence of symptoms of active IBD. The effects of IBD on the skeleton are complex. Protein-calorie malnutrition, inactivity, hypogonadism, deficits in calcium intake and vitamin D consumption and synthesis, stunted growth in children, decreased skeletal muscle mass, and inflammation all likely play a role. Preliminary studies suggest that the dysbiotic intestinal microbial flora present in IBD may also affect bone at a distance. Several mechanisms are possible. T cells activated by the gut microbiota may serve as "inflammatory shuttles" between the intestine and bone. Microbe-associated molecular patterns leaked into the circulation in IBD may activate immune responses in the bone marrow by immune cells and by osteocytes, osteoblasts, and osteoclasts that lead to decreased bone formation and increased resorption. Finally, intestinal microbial metabolites such as H2S may also affect bone cell function. Uncovering these mechanisms will enable the design of microbial cocktails to help restore bone mass in patients with IBD.
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Affiliation(s)
- Francisco A Sylvester
- Division Chief of Pediatric Gastroenterology, The University of North Carolina at Chapel Hil, 333 South Columbia Street, MacNider Hall 247, Chapel Hill, NC, 27599-7229, USA.
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16
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Shrestha MP, Ruel J, Taleban S. Healthcare maintenance in elderly patients with inflammatory bowel disease. Ann Gastroenterol 2017; 30:273-286. [PMID: 28469357 PMCID: PMC5411377 DOI: 10.20524/aog.2017.0130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 01/20/2017] [Indexed: 02/06/2023] Open
Abstract
The increasing number of older patients (age ≥60 years) with inflammatory bowel disease (IBD) highlights the importance of healthcare maintenance in this vulnerable population. Older IBD patients are more susceptible and have higher rates of many disease- and treatment-related adverse effects. Compared to younger IBD patients, older patients are at increased risk for infection, malignancy, bone disease, eye disease, malnutrition and thrombotic complications. Preventive strategies in the elderly differ from those in younger adults and are imperative. Changes to the immune system with aging can decrease the efficacy of vaccinations. Cancer screening guidelines in older IBD patients have to account for unique considerations, such as life expectancy, functional performance status, multimorbidity, financial status, and patient desires. Additionally, providers need to be vigilant in screening for osteoporosis, ocular disease, depression, and adverse events arising from polypharmacy.
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Affiliation(s)
- Manish P Shrestha
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona (Manish P. Shrestha)
| | - Joannie Ruel
- Division of Gastroenterology, University of Sherbrooke, Sherbrooke, Quebec, Canada (Joannie Ruel)
| | - Sasha Taleban
- Division of Gastroenterology, University of Arizona College of Medicine, Tucson, Arizona (Sasha Taleban).,Department of Medicine, University of Arizona Center of Aging, Tucson, Arizona (Sasha Taleban), USA
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17
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ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am J Gastroenterol 2017; 112:241-258. [PMID: 28071656 DOI: 10.1038/ajg.2016.537] [Citation(s) in RCA: 320] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.
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18
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Abstract
Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Osteoporosis Center, Park Nicollet Clinic, HealthPartners, Minneapolis, MN, USA; Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MD, USA.
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19
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Tsai MS, Lin CL, Tu YK, Lee PH, Kao CH. Risks and predictors of osteoporosis in patients with inflammatory bowel diseases in an Asian population: a nationwide population-based cohort study. Int J Clin Pract 2015; 69:235-41. [PMID: 25472555 DOI: 10.1111/ijcp.12526] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/22/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We investigated the inflammatory bowel disease (IBD) specific predictors of osteoporosis and pathological fracture by analysing the Taiwan National Health Insurance Research Database. METHODS Totally, we enrolled 3141 IBD patients and 12,564 age- and sex-matched controls. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of osteoporosis and pathological fracture in both cohorts. RESULTS Inflammatory bowel disease patients had significantly higher comorbidity-adjusted rates of osteoporosis and pathological fracture compared with controls [adjusted hazard ratio (aHR), 1.31; 95% CI, 1.09-1.60, p = 0.004]. Further analysis indicated that women (aHR, 1.36; 95% CI, 1.09-1.70, p = 0.008), middle-aged patients (aHR, 1.74; 95% CI, 1.25-2.41, p = 0.001), patients with Crohn's disease (aHR, 1.33; 95% CI, 1.09-1.64, p = 0.006) and patients without comorbidities (aHR, 1.81; 95% CI, 1.23-2.67, p = 0.003) exhibited excessive risks of osteoporosis. Moreover, patients requiring hospitalisation for IBD exhibited the highest risk of developing osteoporosis (aHR, 4.46; 95% CI, 2.74-7.27, p < 0.001) and pathological fracture (aHR, 17.1; 95% CI, 5.78-50.9, p < 0.001). CONCLUSIONS Patients with IBD, particularly women, middle-aged patients and patients without comorbidities, are associated with a long-term risk of osteoporosis. The risks of osteoporosis and pathological fracture were highest in patients requiring hospitalisation for IBD.
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Affiliation(s)
- M-S Tsai
- Department of Surgery, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
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20
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Krajcovicova A, Hlavaty T, Killinger Z, Miznerova E, Toth J, Letkovsky J, Nevidanska M, Cierny D, Koller T, Zelinkova Z, Huorka M, Payer J. Combination therapy with an immunomodulator and anti-TNFα agent improves bone mineral density in IBD patients. J Crohns Colitis 2014; 8:1693-701. [PMID: 25175812 DOI: 10.1016/j.crohns.2014.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE There is a high prevalence of low bone mineral density (BMD) among patients with inflammatory bowel disease (IBD) although there is a lack of clinical data on the impact of IBD specific medications and recommended vitamin D (VD) and calcium (Ca) supplements on it. DESIGN The cohort consisted of 150 IBD patients. The average change in BMD at the lumbar spine per year (∆BMDL/year) was calculated and the impact of clinical characteristics, medications and VD and Ca supplements was analysed. RESULTS The prevalence of osteopenia was 69/150 (46%) and osteoporosis was identified in 15/150 (10%) patients at baseline. The presence of osteoporosis was associated with the disease duration OR=1.07 per year of disease duration (95% CI=1.01-1.14), p=0.03. The average ∆BMDL/year was 0.010 g/cm(2)/year. Among patients with no IS the ∆BMDL/year was -0.001±0.010 g/cm(2)/year, with AZA -0.001±0.013 g/cm(2)/year, with anti-TNFα 0.003±0.006 g/cm(2)/year and with COMBO 0.027±0.004 g/cm(2)/year; p<0.05 COMBO vs any other subgroup. ∆BMDL/year among patients treated with CS was -0.031±0.012 g/cm(2)/year versus CS free patients 0.013±0.004 g/cm(2)/year; p<0.001. There was no effect of VD/Ca supplementation on BMDL. CONCLUSIONS The prevalence of low BMD was 55%. Duration of disease was the only independent predictor of low BMD. The BMDL was reduced by high cumulative dose of CS and improved by combined anti-TNFα/AZA therapy. The supplementation with recommended doses of VD and Ca had no effect on BMDL.
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Affiliation(s)
- Anna Krajcovicova
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia.
| | - Tibor Hlavaty
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | | | - Ema Miznerova
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Jozef Toth
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Juraj Letkovsky
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Monika Nevidanska
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Daniel Cierny
- Osteocenter, University Hospital Bratislava, Slovakia
| | - Tomas Koller
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Zuzana Zelinkova
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Martin Huorka
- Gastroenterology and Hepatology Unit, University Hospital Bratislava, Slovakia
| | - Juraj Payer
- Osteocenter, University Hospital Bratislava, Slovakia
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21
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Abstract
Osteoporosis is a skeletal disease characterized by decreased bone mass and microarchitectural changes in bone tissue that increase the susceptibility to fracture. Secondary osteoporosis is loosely defined as low bone mineral density or increased risk of fragility fracture caused by any factor other than aging or postmenopausal status. The purpose of this review is to discuss the current understanding of the pathophysiology and contribution to fracture risk of many of the more common causes of secondary osteoporosis, as well as diagnostic considerations, outlined by organ system. While not comprehensive, included are a wide array of diseases, conditions, and medications that have been associated with bone loss and susceptibility to fractures. The hope is to highlight the importance to the general clinician of screening for and treating the osteoporosis in these patients, so to limit the resultant increased morbidity associated with fractures.
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Affiliation(s)
- Gregory R Emkey
- Pennsylvania Regional Center for Arthritis & Osteoporosis Research, 1200 Broadcasting Road, Suite 200, Wyomissing, PA 19610, USA.
| | - Sol Epstein
- Mt Sinai School of Medicine, I Gustave Levy Place New York, New York, NY, USA
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22
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Abstract
Osteopenia and osteoporosis are common manifestations in inflammatory bowel diseases (IBD) but the pathogenetic mechanism of bone loss in IBD is only partially understood. There is evidence that fat mass is an important determinant of the bone mineral density and adipose-derived factors seem to play an important role for the association between fat mass and bone mass. The association between adiposity and low bone density is rather poorly studied in IBD, but emerging data on adipokines in IBD in relation to osteoporosis provide a novel pathophysiological concept that may shed light on the etiology of bone loss in IBD. It could be suggested that adipokines interfere in bone metabolism by altering the sensitive balance between osteoblasts and osteoclasts although further studies in this setting are needed.
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23
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Gupta S, Shen B. Bone loss in patients with the ileostomy and ileal pouch for inflammatory bowel disease. Gastroenterol Rep (Oxf) 2014; 1:159-65. [PMID: 24759961 PMCID: PMC3937994 DOI: 10.1093/gastro/got030] [Citation(s) in RCA: 7] [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: 02/07/2023] Open
Abstract
Low bone mineral density (BMD) or low bone mass is common in patients with inflammatory bowel disease (IBD). Studies have shown that low BMD is also common in patients with ulcerative colitis (UC) even after colectomy and ileal pouch–anal anastomosis (IPAA). The reported frequency of osteopenia ranged from 26–55% and that of osteoporosis ranged from 13–32% in patients with IPAA. Increasing age, low body mass index, lack of calcium supplementation and high inflammatory activity with villous atrophy in the ileo-anal pouch are risk factors for low bone mass in pouch patients. Bone loss is also common in patients with IBD and ostomy. Current professional society guidelines do not specifically address the need for surveillance in patients with ileal pouches or ostomy. A growing body of evidence suggests that patients with ileal pouch or ostomy are at an increased risk of bone loss. Pending prospective studies, screening and surveillance using dual energy X-ray absorptiometry (DEXA) along with calcium/vitamin D supplementation may be beneficial in those patients.
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Affiliation(s)
- Supriya Gupta
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
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24
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Weber NK, Fidler JL, Keaveny TM, Clarke BL, Khosla S, Fletcher JG, Lee DC, Pardi DS, Loftus EV, Kane SV, Barlow JM, Murthy NS, Becker BD, Bruining DH. Validation of a CT-derived method for osteoporosis screening in IBD patients undergoing contrast-enhanced CT enterography. Am J Gastroenterol 2014; 109:401-8. [PMID: 24445572 PMCID: PMC4033296 DOI: 10.1038/ajg.2013.478] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/12/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Osteoporosis and bone fractures are of particular concern in patients with inflammatory bowel disease (IBD). Biomechanical computed tomography (BCT) is an image-analysis technique that can measure bone strength and dual-energy X-ray absorptiometry (DXA)-equivalent bone mineral density (BMD) from noncontrast CT images. This study seeks to determine whether this advanced technology can be applied to patients with IBD undergoing CT enterography (CTE) with IV contrast. METHODS Patients with IBD who underwent a CTE and DXA scan between 2007 and 2011 were retrospectively identified. Femoral neck BMD (g/cm(2)) and T-scores were measured and compared between DXA and BCT analysis of the CTE images. Femoral strength (Newtons) was also determined from BCT analysis. RESULTS DXA- and CTE-generated BMD T-score values were highly correlated (R(2)=0.84, P<0.0001) in this patient cohort (n=136). CTE identified patients with both osteoporosis (sensitivity, 85.7%; 95% confidence interval (CI), 48.7-97.4 and specificity, 98.5%; 95% CI, 94.5-99.6) and osteopenia (sensitivity, 85.1%; 95% CI, 72.3-92.6 and specificity, 85.4%; 95% CI, 76.6-91.3). Of the 16 patients who had "fragile" bone strength by BCT (placing them at the equivalent high risk of fracture as for osteoporosis), 6 had osteoporosis and 10 had osteopenia by DXA. CONCLUSIONS CTE scans can provide hip BMD, T-scores, and clinical classifications that are comparable to those obtained from DXA; when combined with BCT analysis, CTE can identify a subset of patients with osteopenia who have clinically relevant fragile bone strength. This technique could markedly increase bone health assessments in IBD patients already undergoing CTE to evaluate small bowel disease.
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Affiliation(s)
- Nicholas K. Weber
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Jeff L. Fidler
- Department of Radiology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Tony M. Keaveny
- O.N. Diagnostics , Berkeley , California , USA
,Departments of Mechanical Engineering and Bioengineering, UC Berkeley , California , USA
| | - Bart L. Clarke
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Sundeep Khosla
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Joel G. Fletcher
- Department of Radiology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | | | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Sunanda V. Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - John M. Barlow
- Department of Radiology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Naveen S. Murthy
- Department of Radiology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - Brenda D. Becker
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
| | - David H. Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine , Rochester , Minnesota , USA
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25
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Abstract
This review describes the history of U.S. government funding for surveillance programs in inflammatory bowel diseases (IBD), provides current estimates of the incidence and prevalence of IBD in the United States, and enumerates a number of challenges faced by current and future IBD surveillance programs. A rationale for expanding the focus of IBD surveillance beyond counts of incidence and prevalence, to provide a greater understanding of the burden of IBD, disease etiology, and pathogenesis, is provided. Lessons learned from other countries are summarized, in addition to potential resources that may be used to optimize a new form of IBD surveillance in the United States. A consensus recommendation on the goals and available resources for a new model for disease surveillance are provided. This new model should focus on "surveillance of the burden of disease," including (1) natural history of disease and (2) outcomes and complications of the disease and/or treatments.
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26
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Bern EM, Bousvaros A. Loss of response to biologics versus increased risk of lymphoma in children with inflammatory bowel disease: the clinician’s conundrum. Expert Rev Clin Immunol 2014; 9:117-27. [DOI: 10.1586/eci.12.97] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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27
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Walldorf J, Krummenerl A, Engler K, Busch J, Dollinger MM, Seufferlein T, Albert JG. Health care for osteoporosis in inflammatory bowel disease: unmet needs in care of male patients? J Crohns Colitis 2013; 7:901-7. [PMID: 23333038 DOI: 10.1016/j.crohns.2012.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 10/27/2012] [Accepted: 12/18/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Osteoporosis is a frequent complication of inflammatory bowel disease (IBD). It may be related to IBD itself or to its therapy. In this study, the quality of care regarding diagnosis and treatment of osteoporosis was examined. METHODS In this retrospective, monocentric study 293 consecutive patients with IBD (98 ulcerative colitis, 195 Crohn's disease) were included. Information on age, gender, weight, nicotine abuse, course, disease pattern and medication was assessed, results of dual X-ray absorptiometry (DEXA-scan) were evaluated. RESULTS DEXA-scan was performed in 174 patients (59 male, 115 female). Bone mineral density (BMD) was impaired in 38.5% of these patients. Male patients were diagnosed more often with osteopenia or osteoporosis than females (55.9% vs. 29.6%, p=0.03) and had a risk of bone disease comparable to postmenopausal women. Additionally, duration of corticosteroid treatment and IBD were identified as risk factors for osteoporosis. Follow up DEXA-scan demonstrated an overall deterioration of BMD in patients with normal baseline results. CONCLUSIONS While in general, women are considered at higher risk for osteoporosis, male patients had a higher risk of impaired BMD, especially when under treatment with corticosteroids. The high incidence of reduced BMD supports the recommendation to screen patients with IBD at an early stage of disease, although a possible bias has to be considered for patients at a tertial referral centre for IBD. Patients with normal baseline DEXA-scan were still at risk to develop bone disease and it seems advisable to monitor patients with IBD for reduced BMD continually.
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Affiliation(s)
- Jens Walldorf
- Department of Internal Medicine I, Martin Luther University of Halle-Wittenberg, Germany.
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28
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Trabelsi ABS, Abdellaoui F, Ksiaa M, Souguir A, Zeglaoui H, Ben Rejeb M, Brahem A, Ajmi S, Jmaa A. [The decrease in bone density in chronic inflammatory bowel disease: prevalence and risk factors]. Pan Afr Med J 2013; 15:70. [PMID: 24198872 PMCID: PMC3809964 DOI: 10.11604/pamj.2013.15.70.2859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 06/16/2013] [Indexed: 01/13/2023] Open
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29
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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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30
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Khan N, Abbas AM, Almukhtar RM, Khan A. Prevalence and predictors of low bone mineral density in males with ulcerative colitis. J Clin Endocrinol Metab 2013; 98:2368-75. [PMID: 23596137 DOI: 10.1210/jc.2013-1332] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Low bone mineral density (BMD) is common in patients with inflammatory bowel diseases. OBJECTIVE The objective of the study was to assess the prevalence and the predictors of low BMD (osteoporosis or osteopenia) and fragility fractures among men with ulcerative colitis. DESIGN This was a retrospective database analysis. SETTING The study was conducted at a nationwide Veterans Affairs health care system. PATIENTS Male ulcerative colitis patients who were followed up in the Veterans Affairs system between 2001 and 2011 were identified using the International Classification of Diseases, ninth revision (ICD-9). MAIN OUTCOME MEASURES We identified patients with low BMD and fragility fractures using ICD-9 codes. Steroid exposure was assessed using pharmacy data. A multivariate analysis was used to identify the independent effect of systemic steroids on the risk of low BMD and fragility fractures. RESULTS We identified 34 665 patients. Among them, 31% used steroids. The prevalence of low BMD was 15.8% and 7.1% among those who used and did not use steroids, respectively (P < .001). Prevalence of fragility fractures was 7.9%, 4.4%, and 1.1% for those with osteoporosis and osteopenia and those without low BMD, respectively (P < .001). Steroid exposure showed a dose-response pattern, patients who had cumulative prednisone exposure of greater than 11 136 mg (10th decile) were more likely to develop low BMD (odds ratio 8.9, P < .001) and fragility fractures (odds ratio 1.8, P < .001) as compared with non-steroid users after controlling for other possible predictors. CONCLUSION In this nationwide cohort, the prevalence of low BMD was higher than what was reported for the general male population. There was a strong correlation between the cumulative steroid use and the risk of low BMD. Both steroids and low BMD were independent risk factors for fragility fractures.
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Affiliation(s)
- Nabeel Khan
- Southeast Louisiana Veterans Health Care System, Section of Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana 70112, USA.
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Azzopardi N, Ellul P. Risk factors for osteoporosis in Crohn's disease: infliximab, corticosteroids, body mass index, and age of onset. Inflamm Bowel Dis 2013; 19:1173-8. [PMID: 23511037 DOI: 10.1097/mib.0b013e31828075a7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We analyzed the characteristics associated with increased risk of osteoporosis in patients with Crohn's disease in Malta. METHOD Eighty-three patients with histologically and endoscopically confirmed Crohn's disease underwent a DEXA bone density scan and their phenotypic characteristics were analyzed. RESULTS There was a significant association between body mass index and bone mineral density (P = 0.004) and a significant difference in the T scores of patients according to age at diagnosis (Montreal Classification: P = 0.0006) with patients diagnosed <17 years (n = 13) having lower T scores than those diagnosed at older age groups (n = 70). There was a significant difference between the T scores of patients on infliximab (n = 33) and those not on biological therapy (n = 50, P = 0.0058). Patients with high cumulative corticosteroid doses (>10 mg/d for >3 mo, n = 18) had lower bone mineral densities than patients who received smaller corticosteroid doses (P = 0.013). There was however no significant difference in the T scores of patients according to disease location (P = 0.18), disease type (P = 0.64), gender (P = 0.30), and history of ileal resection (P = 0.68). There was also no significant correlation between disease duration and T scores (hip) (P = 0.61). CONCLUSIONS Low body mass index, early disease onset, high corticosteroid doses and, anti-tumor necrosis factor α therapy are associated with increased risk of osteoporosis. Lower T scores in patients on infliximab occur as patients receiving this therapy have more severe inflammation, which is associated with elevated osteoclastogenic factors, rather than as a side-effect of the anti-tumor necrosis factor-α therapy.
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Affiliation(s)
- Neville Azzopardi
- Division of Gastroenterology, Mater Dei Hospital (Malta), Mellieha, Malta.
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Kwon KA, Ku YS. Can early onset of disease be one of the risk factors for low bone mineral density in patients with inflammatory bowel disease? Clin Endosc 2013; 46:5-6. [PMID: 23424712 PMCID: PMC3572351 DOI: 10.5946/ce.2013.46.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 12/19/2012] [Accepted: 12/19/2012] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kwang An Kwon
- Department of Gastroenterology, Gachon University Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
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Terzoudis S, Zavos C, Damilakis J, Neratzoulakis J, Dimitriadi DA, Roussomoustakaki M, Kouroumalis EA, Koutroubakis IE. Increased fracture risk assessed by fracture risk assessment tool in Greek patients with Crohn's disease. Dig Dis Sci 2013; 58:216-21. [PMID: 22865352 DOI: 10.1007/s10620-012-2326-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/17/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND The World Health Organization has recently developed the fracture risk assessment tool (FRAX) based on clinical risk factors and bone mineral density (BMD) for evaluation of the 10-year probability of a hip or a major osteoporotic fracture. The aim of this study was to evaluate the use of the FRAX tool in Greek patients with inflammatory bowel disease (IBD). METHODS FRAX scores were applied to 134 IBD patients [68 Crohn's disease (CD); 66 ulcerative colitis (UC)] who underwent dual-energy X-ray absorptiometry scans at the femoral neck and lumbar spine during the period 2007-2012. Calculation of the FRAX scores, with or without BMD, was made through a web-based probability model used to compute individual fracture probabilities according to specific clinical risk factors. RESULTS The median 10-year probability of a major osteoporotic fracture for IBD patients based on clinical data was 7.1%, and including the BMD was 6.2%. A significant overestimation with the first method was found (P = 0.01). Both scores with and without BMD were significantly higher in CD patients compared with UC patients (P = 0.02 and P = 0.005, respectively). The median 10-year probability of hip fracture based on clinical data was 0.8%, and including the BMD was 0.9%. The score with use of BMD was significantly higher in CD compared with UC patients (P = 0.04). CONCLUSIONS CD patients have significantly higher FRAX scores and possibly fracture risk compared with UC patients. The clinical FRAX score alone seems to overestimate the risk of osteoporotic fracture in Greek IBD patients.
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Affiliation(s)
- Sotirios Terzoudis
- Department of Gastroenterology, University Hospital of Heraklion, P.O. Box 1352, 71110, Heraklion, Crete, Greece
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de Pablo P, Cooper MS, Buckley CD. Association between bone mineral density and C-reactive protein in a large population-based sample. ACTA ACUST UNITED AC 2012; 64:2624-31. [PMID: 22487938 DOI: 10.1002/art.34474] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Several studies suggest that bone mineral density (BMD) is reduced in chronic inflammatory diseases. Higher serum levels of C-reactive protein (CRP) have been associated with lower BMD in women and older adults. However, it is not clear whether this association holds in a representative sample of the general population. The purpose of this study was to examine the relationship between BMD and CRP level in a large representative US population-based sample from the National Health and Nutrition Examination Survey (NHANES). METHODS We included participants age ≥20 years with BMD (total and subregions) measured by dual x-ray absorptiometry scans and complete information on covariates from NHANES. The association between CRP level and BMD was evaluated using multivariate linear regression models, adjusting for potential confounders and further adjusting for comorbid diseases, medications, and serum vitamin D levels. RESULTS The study sample included 10,475 participants (53% Caucasian, 22% Mexican American, 18% African American, and 7% other races). Men had higher BMD and lower CRP concentrations than women. BMD (total body BMD as well as subtotal BMD and BMD of the extremities, ribs, and trunk subregions) was inversely associated with quintiles of CRP concentration both in men and in women in a dose-dependent manner (for total BMD, P for trend < 0.0001 for men, P for trend = 0.0005 for women). The associations were independent of medications, comorbidities, and other potential confounders. The results remained largely unchanged with further adjustment for serum vitamin D levels. CONCLUSION Among men and women in a large representative population-based sample, the CRP level was inversely and independently associated with total BMD in a dose-dependent manner.
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Affiliation(s)
- Paola de Pablo
- University of Birmingham College of Medical and Dental Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, and Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK.
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Karve S, Candrilli S, Kappelman MD, Tolleson-Rinehart S, Tennis P, Andrews E. Healthcare utilization and comorbidity burden among children and young adults in the United States with systemic lupus erythematosus or inflammatory bowel disease. J Pediatr 2012; 161:662-670.e2. [PMID: 22578787 DOI: 10.1016/j.jpeds.2012.03.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 02/16/2012] [Accepted: 03/23/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE We sought to assess the feasibility of using a health insurance claims database to estimate the prevalence and health care utilization and costs among children diagnosed with systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD). STUDY DESIGN This was a retrospective analysis of the LifeLink insurance claims database for the years 2000-2006. Children (0-15 years) and young adults (16-25 years) with ≥ 2 diagnosis claims for SLE or IBD were selected as the 2 cohorts of interest. For each member of the SLE and IBD cohorts, 2 individuals were randomly selected for a matched comparison group. All the analyses were descriptive in nature, CI for differences between means and 2 proportions for measures including health care utilization, comorbidity burden were based on t tests and 2-group tests of proportions. RESULTS We identified 278 patients with SLE (prevalence estimate: 7.9 per/100000 population) and 1174 patients with IBD (33.2 per/100000 population). The mean annual total medical costs was substantially higher for the SLE (difference: $22223; 95% CI: $14961-$29485) and IBD (difference: $16238; 95% CI: $14395-$18082) cohorts compared with those of the comparator cohort. We observed higher comorbidity burdens in the SLE and IBD cohorts than we saw in the comparator cohort. CONCLUSIONS Administrative claims data can be a useful tool for assessing the comparative prevalence and associated resource utilization of rare conditions such as SLE and IBD.
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Affiliation(s)
- Sudeep Karve
- RTI Health Solutions, Research Triangle Park, NC 27709-2194, USA.
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Vázquez MA, Lopez E, Montoya MJ, Giner M, Pérez-Temprano R, Pérez-Cano R. Vertebral fractures in patients with inflammatory bowel disease compared with a healthy population: a prospective case-control study. BMC Gastroenterol 2012; 12:47. [PMID: 22584049 PMCID: PMC3438096 DOI: 10.1186/1471-230x-12-47] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 05/04/2012] [Indexed: 02/08/2023] Open
Abstract
Background A prospective study was performed to compare the prevalence of morphometric vertebral fractures (MVF) between patients with inflammatory bowel disease (IBD) and healthy subjects and to identify predictive factors of fracture. Methods A total of 107 patients with IBD (53 with Crohn’s disease and 54 with ulcerative colitis) and 51 healthy subjects participated in the study. Information about anthropometric parameters, toxins, previous fractures, and parameters related to this disease were evaluated. The index of vertebral deformity, bone mass density (BMD), and biochemical parameters were calculated. Results A total of 72 fractures were detected in 38.32% of patients with IBD, and 10 fractures were detected in 13.73% of healthy subjects; the risk of fracture in patients with IBD was higher than that in control subjects (OR, 4.03; 95% CI, 1.652–9.847; p < 0.002). We found no correlation between fracture and BMD in patients with IBD (lumbar spine, r = −0.103, p = 0.17 and femoral neck, r = −0.138, p = 0.07). Corticosteroid treatment was not associated with prevalent vertebral fractures nor with taking corticosteroids (r = 0.135, p = 0.14) or the duration for which they were taken (r = 0.08, p = 0.38), whereas this relationship was present in the controls (r = −0.365, p = 0.01). In the multivariate analysis, none of the measured parameters were significantly predictive of fracture, only to manifested IBD. Hypovitaminosis D was observed in 55.14% of patients with IBD. Conclusions The prevalence of morphometric vertebral fractures is higher in patients with IBD than in the healthy population, without association with BMD or corticoid treatment. Simply having IBD was proven to be a predictive factor of fracture. We observed a high incidence of hypovitaminosis D in patients with IBD.
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Hovde &O, Moum BA. Epidemiology and clinical course of Crohn's disease: Results from observational studies. World J Gastroenterol 2012; 18:1723-31. [PMID: 22553396 PMCID: PMC3332285 DOI: 10.3748/wjg.v18.i15.1723] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 01/12/2012] [Accepted: 01/19/2012] [Indexed: 02/06/2023] Open
Abstract
The authors review the clinical outcome in patients with Crohn’s disease (CD) based on studies describing the natural course of the disease. Population-based studies have demonstrated that the incidence rates and prevalence rates for CD have increased since the mid-1970s. The authors search for English language articles from 1980 until 2011. Geographical variations, incidence, prevalence, smoking habits, sex, mortality and medications are investigated. An increasing incidence and prevalence of CD have been found over the last three decades. The disease seems to be most common in northern Europe and North America, but is probably increasing also in Asia and Africa. Smoking is associated with an increased risk of developing CD. Age < 40 at diagnosis, penetrating/stricturing complications, need for systemic steroids, and disease location in terminal ileum are factors associated with higher relapse rates. A slight predominance of women diagnosed with CD has been found. Ileocecal resection is the most commonly performed surgical procedure, and within the first five years after the diagnosis about one third of the patients have had intestinal surgery. Smoking is associated with a worse clinical course and with increased risk of flare-ups. In most studies the overall mortality is comparable to the background population. To date, the most effective treatment options in acute flares are glucocorticosteroids and tumor necrosis factor (TNF)-α- blockers. Azathioprine/methotrexate and TNF-α-blockers are effective in maintaining remission.
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Reyes García R, Jódar Gimeno E, García Martín A, Romero Muñoz M, Gómez Sáez JM, Luque Fernández I, Varsavsky M, Guadalix Iglesias S, Cano Rodriguez I, Ballesteros Pomar MD, Vidal Casariego A, Rozas Moreno P, Cortés Berdonces M, Fernández García D, Calleja Canelas A, Palma Moya M, Martínez Díaz-Guerra G, Jimenez Moleón JJ, Muñoz Torres M. [Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]. ACTA ACUST UNITED AC 2012; 59:174-96. [PMID: 22321561 DOI: 10.1016/j.endonu.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. PARTICIPANTS Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. METHODS Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. CONCLUSIONS The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.
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Navaneethan U, Shen L, Venkatesh PGK, Hammel J, Patel V, Remzi FH, Kiran RP. Influence of ileal pouch anal anastomosis on bone loss in ulcerative colitis patients. J Crohns Colitis 2011; 5:415-22. [PMID: 21939915 DOI: 10.1016/j.crohns.2011.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/12/2011] [Accepted: 04/13/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Patients with ulcerative colitis (UC) are at an increased risk for low bone mineral density (BMD). It is unclear whether proctocolectomy with ileal pouch-anal anastomosis (IPAA) for UC alters the risk of bone loss. The aim of this study was to compare BMD in UC patients with and without IPAA. METHODS A total of 267 patients with UC and IPAA (study group) were compared to 119 UC patients without IPAA (control group) in this cross-sectional study. The demographic and clinical variables including dual-energy X-ray absorptiometry scan results were compared. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. Univariate and multivariate analyses were performed to assess risk factors associated with low BMD. Age, gender, race, smoking status, steroid use, alcohol use, body mass index, years of absent estrogen protection, use of calcium, vitamin D supplements and disease duration were selected as covariates. RESULTS 83 (31.1%) had low BMD in the study group vs. 18 (15.1%) in the control group (p=0.001). 2/13 (15.4%) had low BMD before surgery. The mean age of patients in the study and control groups were 44.7 ± 14.1 vs. 52.4 ± 17.7 years, respectively (p<0.001). The hip BMD was lower in the study group (0.93 ± 0.17 g/cm2) than that in the control group (0.98 ± 0.17 g/cm2) (p=0.038). Fragility fracture was documented in 23 (8.6%) patients in the study group vs. 3 (2.5%) in the control group (p=0.038) Sixty-four (24.0%) of the study group patients were using corticosteroids after surgery in contrast to 93 (78.2%) in the control group (p<0.001). On multivariable analyses, covariate adjusted factors associated with a low BMD in UC patients were advanced age [odds ratio (OR) 1.51 per 5 years; 95% confidence interval [CI], 1.34-1.71], low body mass index (OR=2.37 per 5 kg/m(2) decrease; 95% CI, 1.68-3.36), and the presence of IPAA (OR=6.02; 95% CI, 2.46-14.70). For the 13 IPAA patients who had information available, BMD before IPAA was low. After a median of 46 (Range 7-84) months after IPAA, BMD improved in 7/13 patients (53.8%), while it continued to be low in 6/13 (46.2%) patients. CONCLUSIONS Low BMD is common in patients with UC. The risk appears to persist even after colectomy and IPAA surgery suggesting that these patients need to be monitored for bone loss.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Etzel JP, Larson MF, Anawalt BD, Collins J, Dominitz JA. Assessment and management of low bone density in inflammatory bowel disease and performance of professional society guidelines. Inflamm Bowel Dis 2011; 17:2122-9. [PMID: 21910174 DOI: 10.1002/ibd.21601] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 11/05/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients have increased prevalence of osteoporosis, leading to guideline recommendations for bone mineral density (BMD) testing. The study aim was to identify predictors of BMD testing and treatment and assess guideline effectiveness to identify IBD patients with osteoporosis. METHODS Records of all IBD patients at seven medical facilities were reviewed for clinical data and BMD testing from January 1996 through October 2006. RESULTS A total of 2035 patients had 317 bone density tests performed. Osteopenia was found in 48% of patients, osteoporosis in 26%. Among patients meeting guideline criteria for BMD testing and ≥1 year of follow-up, 23.3% underwent testing. The strongest predictors of testing were menopause (adjusted hazard ratio [AHR] 3.02) and receiving care at a tertiary center (AHR 2.56). Testing rates were low in patients with age ≥60 years, ulcerative colitis, and a history of inpatient IBD treatment. Osteoporotic patients received calcium/vitamin D and bisphosphonates in 59% and 75% of cases, respectively. Osteoporotic males had a 37% rate of hypogonadism. Guideline criteria do not distinguish patients with osteoporosis. The criteria had a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 23%, 27%, and 81% for osteoporosis in the tested population, respectively. CONCLUSIONS Osteoporosis is highly prevalent in the IBD population, but BMD testing and osteoporosis treatments are underutilized. Male hypogonadism is common in osteoporotic IBD patients. Guidelines do not identify IBD patients with osteoporosis.
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Affiliation(s)
- Jason P Etzel
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Alteraciones del metabolismo óseo en 100 pacientes con enfermedad inflamatoria intestinal. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:379-84. [DOI: 10.1016/j.gastrohep.2011.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/05/2011] [Accepted: 03/09/2011] [Indexed: 01/05/2023]
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Kappelman MD, Galanko JA, Porter CQ, Sandler RS. Risk of diagnosed fractures in children with inflammatory bowel diseases. Inflamm Bowel Dis 2011; 17:1125-30. [PMID: 20872833 PMCID: PMC3012144 DOI: 10.1002/ibd.21472] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 07/30/2010] [Indexed: 12/30/2022]
Abstract
BACKGROUND Decreased bone mass is common in children with inflammatory bowel disease (IBD); however, fracture risk is unknown. We sought to evaluate fracture risk in children with IBD as compared to unaffected controls and determine whether this risk is affected by geographical region (a proxy for sun/vitamin D exposure) and oral steroid use. METHODS We identified cases of Crohn's disease (CD) and ulcerative colitis (UC), less than 20 years of age, using administrative data from 87 health plans. Each case was matched to three controls on the basis of age, gender, and geographical region. We identified fractures in cases and controls using ICD-9 diagnosis codes and measured oral steroid exposure using NDC codes. RESULTS The study included 733 children with CD, 488 with UC, and 3287 controls (mean age 15 years). IBD was not associated with a higher risk of fracture at any site (CD odds ratio [OR] 0.8, 95% confidence interval [CI] 0.6-1.1; UC OR 1.4, 95% CI 1.0-2.1) or at multiple sites (CD OR 0.8, 95% CI 0.4-1.7; UC OR 0.4, 95% CI 0.1-1.4). Among IBD patients we did not identify any significant differences in the fracture rate between those residing in the Northeast/Midwest versus the South (OR 1.3, 95% CI 0.8-2.2). Steroid exposure was not associated with the occurrence of fractures (P = 0.6). CONCLUSIONS Children with IBD are no more likely to have experienced a diagnosed fracture than age-, sex-, and gender-matched controls.
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Hill RJ, Brookes DSK, Davies PSW. Bones in pediatric Crohn's disease: a review of fracture risk in children and adults. Inflamm Bowel Dis 2011; 17:1223-8. [PMID: 20824813 DOI: 10.1002/ibd.21471] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 07/30/2010] [Indexed: 12/17/2022]
Abstract
There is evidence to suggest that the inflammation associated with Crohn's disease (CD) impacts the bone health of patients, predisposing them to early onset osteoporosis and increasing their risk of fracture. Fractures have been documented in patients with CD, with a high proportion of these being found during young adulthood, which suggests that these patients are not simply fracturing as a result of the normal aging process but rather due to the presence of CD. In population terms, patients with CD have increased risk of fracture compared with the general population. Studies in children suggest that, irrespective of time on corticosteroid therapy, the underlying systemic inflammation associated with CD is an independent detrimental influence on the bone health of children with CD. This poses the question as to whether the onset of disease in childhood predisposes the individual to increased risk of future fractures later in life, as a result of decreased peak bone mass during the growing years. It is generally believed that dual energy x-ray absorptiometry-assessed areal bone mineral density is a good indicator of fracture risk; however, several studies have shown this may not be the case. New research, utilizing peripheral quantitative computed tomography, which provides a true volumetric assessment of bone, suggests altered bone geometry in patients with CD, which poses a structural threat by being more brittle and susceptible to damage accumulation.
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Affiliation(s)
- Rebecca J Hill
- University of Queensland, Children's Nutrition Research Centre, Herston, Qld, Australia.
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Goodhand JR, Kamperidis N, Nguyen H, Wahed M, Rampton DS. Application of the WHO fracture risk assessment tool (FRAX) to predict need for DEXA scanning and treatment in patients with inflammatory bowel disease at risk of osteoporosis. Aliment Pharmacol Ther 2011; 33:551-8. [PMID: 21198706 DOI: 10.1111/j.1365-2036.2010.04554.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although patients with inflammatory bowel disease (IBD) are at increased risk of osteoporosis, low bone mineral density (BMD) alone confers only a modest increase in risk of fracture. The FRAX score, developed by the WHO, is a free web-based clinical scale assessing the 10-year fracture risk and need for lifestyle advice/reassurance, dual X-ray absorptiometry (DEXA) scanning or preventive treatment. AIM To assess the accuracy of pre-BMD FRAX scores in identifying at risk IBD patients needing BMD measurement (intermediate risk) and/or therapy (high risk). METHODS We calculated FRAX scores retrospectively in 116 consecutive IBD out-patients (81 Crohn's disease, 35 ulcerative colitis), who were having DEXA scans in 2005-2009 because they were considered at risk of osteoporosis. RESULTS On DEXA scans, 47% (38/81) and 12% (10/81) patients with Crohn's disease were osteopaenic and osteoporotic, respectively; equivalent figures for patients with UC were 34% (12/35) and 14% (5/35). The clinical FRAX score alone, when compared with the FRAX score including the BMD result, had a sensitivity of 100% (95% CI: 70-100%), specificity of 40% (95% CI: 31-50%), positive predictive value of 16% (95% CI: 9-27%) and negative predictive value of 100% (95% CI: 90-100%) in identifying those patients needing BMD measurement (intermediate risk) or preventive therapy (high risk). CONCLUSIONS In patients with IBD perceived to be at risk of osteoporosis and/or osteopaenia, the clinical FRAX score alone can predict accurately the risk of osteoporotic fracture, and thereby reduce the need for DEXA scans and unnecessary anti-osteoporosis treatment.
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Affiliation(s)
- J R Goodhand
- Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, UK
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Mascarenhas MR, Thayu M. Pediatric inflammatory bowel disease and bone health. Nutr Clin Pract 2011; 25:347-52. [PMID: 20702839 DOI: 10.1177/0884533610374962] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Childhood and adolescence are important periods for bone development. Any disease that affects bone health has the potential to affect the bones not only in the short term but also later in life. Bone health abnormalities in patients with inflammatory bowel disease are being increasingly recognized. Screening the at-risk patient is important so that appropriate treatments can be instituted. Treatment options are limited to vitamin D and calcium supplementation, control of underlying disease activity, and appropriate physical activity. The role of bisphosphonates in these patients needs to be better studied, and treatment with bisphosphonates may be considered for some patients in consultation with a bone health expert.
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Affiliation(s)
- Maria R Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19014, USA
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Peyrin-Biroulet L, Loftus EV, Colombel JF, Sandborn WJ. Long-term complications, extraintestinal manifestations, and mortality in adult Crohn's disease in population-based cohorts. Inflamm Bowel Dis 2011; 17:471-8. [PMID: 20725943 DOI: 10.1002/ibd.21417] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Accepted: 06/10/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic, progressive, destructive disease. Numerous intestinal and extraintestinal complications and manifestations can occur during its clinical course. This literature review summarizes our current knowledge of the long-term complications, extraintestinal complications, and mortality in CD in adults as reported in population-based studies that include long-term follow-up results. METHODS A literature search of English and non-English language publications listed in the electronic databases of Medline (source PubMed, 1935 to July, 2009). RESULTS The relative risk of incident fractures is increased in CD patients by ≈30%-40%. These patients have also have a 3-fold increased risk of deep venous thrombosis and pulmonary embolism. A variety of extraintestinal manifestations (primary sclerosing cholangitis, ankylosing spondylitis, iritis/uveitis, pyoderma gangrenosum, erythema nodosum) and diseases (asthma, bronchitis, pericarditis, psoriasis, rheumatoid arthritis, and multiple sclerosis) are associated with CD. The risks of colorectal and small bowel cancers relative to the general population are 1.4-1.9 and 21.1-27.1, respectively. A slightly increased risk of lymphoma, irrespective of medication use, has been reported in a recent meta-analysis of population-based studies. Overall mortality is slightly increased in CD, with a standardized mortality ratio of 1.4. CONCLUSIONS CD is frequently associated with disease complications and extraintestinal conditions. Whether the impact of changing treatment paradigms with increased use of immunosuppressives and biologic agents can reduce disease complications and associated conditions is unknown.
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Ananthakrishnan AN, McGinley EL, Binion DG, Saeian K. Fracture-associated hospitalizations in patients with inflammatory bowel disease. Dig Dis Sci 2011; 56:176-82. [PMID: 20936351 DOI: 10.1007/s10620-010-1433-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 09/09/2010] [Indexed: 01/14/2023]
Abstract
BACKGROUND Maintenance of bone health is an important concern in patients with inflammatory bowel disease (IBD). They may frequently have impaired bone density resulting in greater incidence of fractures. AIMS To examine fracture-associated hospitalization costs in IBD patients from a nationwide representative sample, and to compare the risk factors for such fractures in IBD and non-IBD patients. METHODS We identified discharges with IBD and coexisting codes for hip, vertebral or wrist fractures (IBD-Fr) from the Nationwide Inpatient Sample and compared them with IBD hospitalizations without codes for these fractures. A second analysis was performed using 2008 inpatient data from the Wisconsin Hospital Association (WHA) comparing characteristics of patients with IBD-Fr and non-IBD controls hospitalized for similar fractures. RESULTS There were 1,653 discharges in the IBD-Fr group accounting for 10,461 days of hospital stay and US $46 million in total hospitalization charges. On multivariate analysis, age>65 years [odds ratio (OR) 28.8, 95% confidence interval (CI) 12.3-67.6] and female sex (OR 1.3, 95%CI 1.0-1.6) were associated with higher odds of hospitalization associated with fractures. We found no differences in age, gender, or race among IBD-Fr and non-IBD fracture controls. However, IBD-fractures were twice as likely to be associated with osteoporosis as non-IBD fractures (OR 2.19, 95%CI 1.10-4.33). CONCLUSIONS Older age, female sex, and osteoporosis were more commonly associated with hospitalization for fractures in IBD patients. Osteoporosis appears to be more common among IBD-Fr patients than non-IBD fracture controls.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Gastrointestinal Unit, Massachusetts General Hospital, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA.
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Abstract
OBJECTIVES Chronic pancreatitis (CP) is associated with risk factors that may negatively impact bone and mineral metabolism. The important clinical end point of osteoporosis is "low-trauma" fracture. The purpose of this study was to examine the prevalence of "low-trauma" fracture in patients with CP, compared with fracture rates in "high-risk" gastrointestinal (GI) illnesses, for which metabolic bone disease screening guidelines are in place. METHODS This is a retrospective cohort database study examining patients with CP and "high-risk" GI illnesses seen at a single tertiary care center. Time points ranged between 31 July 1998 and 31 July 2008. The main outcome measure was "low-trauma" fracture prevalence using specific International Classification of Diseases, Ninth Revision, Clinical Modification fracture codes. RESULTS A total of 3,192 CP patients and 1,461,207 non-CP patients were included in the study. The fracture prevalence (patients with fracture per total patients) was as follows: controls, 1.1% (16,208/1,436,699); Crohn's disease, 3.0% (182/6057); CP, 4.8% (154/3192); cirrhosis, 4.8% (805/16,658); celiac disease, 5.0% (74/1480); and postgastrectomy, 5.4% (17/313). Prevalence for each group was statistically greater than controls (P<0.001). CP fracture prevalence was greater than controls (P<0.001) and Crohn's disease (P<0.001), and comparable with the remaining "high-risk" GI illness groups (P>0.05). The odds of fracture (odds ratio (OR), 95% confidence interval (CI)) compared with controls, adjusted for age, gender, and race was: CP 2.4 (2.1, 2.9); Crohn's disease 1.7 (1.5, 2.0); gastrectomy 2.5 (1.5, 4.1); cirrhosis 2.6 (2.4, 2.7); and celiac disease 2.7 (2.1, 3.4). The odds of fracture for each disease group were statistically greater than controls (P<0.0001). CONCLUSIONS The prevalence of low-trauma fracture in CP patients is comparable with or higher than that of "high-risk" GI illnesses, for which osteoporosis screening guidelines exist.
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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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Conklin LS, Oliva-Hemker M. Nutritional considerations in pediatric inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2010; 4:305-17. [PMID: 20528118 DOI: 10.1586/egh.10.23] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Nutrition is a critical part of the management of inflammatory bowel disease (IBD) in children and adults. Malnutrition and micronutrient deficiencies are common at the time of diagnosis and may persist throughout the course of the disease. There are a number of similarities with regards to the nutritional complications and the approach to nutritional management in IBD in both children and adults, but there are also important differences. Growth failure, pubertal delay and the need for corticosteroid-sparing regimens are of higher importance in pediatrics. In the pediatric population, exclusive enteral nutrition may be equivalent to corticosteroids in inducing remission in acute Crohn's disease, and may have benefits over corticosteroids in children. Adherence with exclusive enteral nutrition is better in children than in adults. Iron deficiency anemia is an important problem for adults and children with IBD. Intravenous iron administration may be superior to oral iron supplementation. Ensuring adequate bone health is another critical component of nutritional management in IBD, but guidelines for screening and therapeutic interventions for low bone mineral density are lacking in children.
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