Bone mineral density in patients with inflammatory bowel disease

Relationship between bone mineral density and clinical features in patients with inflammatory bowel disease: a local study in Turkish population

This study aimed to compare the bone mineral density (BMD) of patients with ulcerative colitis (UC) and Crohn's disease (CD) in order to determine the possible risk factors for bone loss. A total of 142 patients with UC (n = 88) and CD (n = 54) participated in the study. They were assessed for gender, body mass index (BMI), disease duration and activity, intestinal site of involvement, history of bowel resection, use of steroids, and extra-intestinal findings and complications. The BMD was measured by dual-energy X-ray absorptiometry. There were no differences in BMD between UC and CD patients. In UC patients, BMI showed a significant positive correlation with BMD. Femoral neck Z scores were lower in patients with extra-intestinal findings and complications. Steroid use, disease activity, disease localization, disease duration, bowel surgery and gender had no influence on BMD. Complications or extra-intestinal involvement were a significant predictor for BMD in both groups.

Improvement of lumbar bone mass after infliximab therapy in Crohn's disease patients

BACKGROUND

Patients with Crohn's disease (CD) have a high risk of developing osteoporosis, but the mechanisms underlying bone mass loss are unclear. Elevated proinflammatory cytokines, such as tumour necrosis factor-alpha (TNFalpha), have been implicated in the pathogenesis of bone resorption.

AIM

To assess whether suppression of TNFalpha with infliximab treatment has a beneficial effect on lumbar bone mass.

METHODS

Adult CD patients who had received infliximab treatment, and who underwent lumbar densitometric evaluation before and during treatment, were selected. Adult CD patients who had never received infliximab treatment were selected as controls. Information regarding age, sex, weight, duration of CD, use of glucocorticoids and bisphosphonates, and signs of disease activity between both densitometric measurements were collected.

RESULTS

Data from 45 patients were analyzed. The control group (n=30, mean [+/- SD] 26.7+/-9 years of age) had a significantly higher increase in body weight between both evaluations (6.26%+/-8%) than the infliximab group (n=15, 30.6+/-13 years), which had an increase of 0.3%+/-7.4%. There was a strong correlation between the final weight and lumbar bone mineral content (BMC) in both groups. The infliximab group had a significant increase in lumbar bone area (4.15%+/-6.6%), BMC (12.8%+/-13.6%) and bone mineral density (8.13%+/-7.7%) between both evaluations (interval 22.6+/-11 months) compared with the control group. The increase in BMC in patients who had received infliximab treatment was significant when compared with control patients who had received glucocorticoids (n=8) or had evidence of disease activity (n=13).

CONCLUSION

Infliximab therapy improved lumbar bone mass independent of nutritional status. This finding suggests that TNFalpha plays a role in bone loss in CD.

Evaluation of densitometric bone-muscle relationships in Crohn's disease

BACKGROUND

Patients with Crohn's disease (CD) are 1.4 to 2.5 times more likely than the normal population to sustain a fracture but the factors involved in the pathogenesis are not clearly understood. Bone mass is affected both by nutrition and by muscular activity. Trauma excepted, the largest voluntary loads on bones come from muscle contraction, not body weight.

AIM

To assess the relationship between bone mass (bone mineral content) and muscle mass (lean mass) in CD patients.

METHODS

Adult CD patients who had had a whole body, lumbar and hip densitometric evaluation were selected. Information regarding age, gender, weight, duration of CD, age at diagnosis, use of glucocorticoids and disease activity during the year before densitometric evaluation and laboratory parameters were collected.

RESULTS

Data from 65 patients (28.8+/-10.6 years, F=44, M=21) were analyzed. Lumbar bone mineral content (BMC), BMC in both hips, total and regional BMC significantly correlated with body weight and total and regional lean mass (LM). In multiple regression analysis, only total LM was shown to be independently associated with lumbar BMC, BMC in both hips and total BMC. LM in upper and lower limbs was shown to be independently associated with BMC in upper and lower limbs, respectively.

CONCLUSIONS

These results suggest that muscular mass and activity, rather than overall body weight, are important determinants of bone mass and, hence of bone strength in Crohn's disease. Thus, the management of bone loss in inflammatory bowel disease should address the effects of both nutrition and exercise on muscle mass.

Juvenile onset of Crohn's disease: a risk factor for reduced lumbar bone mass in premenopausal women

BACKGROUND

Crohn's disease (CD) is associated with reduced bone mass. Bone fragility is the result of both growth-related and age-related factors; thus, exposure to a chronic illness, such as CD, during skeletal growth may compromise peak bone mass. Our aim was to assess whether the onset of CD during skeletal growth had an impact on bone mass in adulthood in premenopausal women.

METHODS

Adult premenopausal CD patients who had a whole body, lumbar and hip bone densitometric evaluation were selected. Information regarding age, gender, weight, duration of CD, age at diagnosis, use of glucocorticoids and disease activity during the year before densitometric assessment and laboratory parameters were collected.

RESULTS

Data from 57 patients (28+/-10 years) were analyzed. Age at diagnosis was independently associated with lumbar bone mineral content (BMC). Lean mass was independently associated with total, lumbar and hip BMC. Patients with a history of onset of CD before 16 years of age (n=20) were 11.6+/-2 years old at diagnosis. They had low lumbar and hip Z scores. They had significantly lower BMC, bone mineral density and Z scores in lumbar area and both hips than those diagnosed after the age of 16. They also had significantly lower lumbar area than those diagnosed after the age of 16.

CONCLUSIONS

The onset of CD during skeletal growth is a risk factor for reduced lumbar and hip bone mass in adulthood in premenopausal women.

Mutifactorial analysis of risk factors for reduced bone mineral density in patients with Crohn’s disease

AIM: To determine the prevalence of osteoporosis in a cohort of patients with Crohn’s disease (CD) and to identify the relative significance of risk factors for osteoporosis.

METHODS: Two hundred and fifty-eight unselected patients (92 M, 166 F) with CD were studied. Bone mineral density (BMD) was measured at the lumbar spine and hip by dual X-ray absorptiometry. Bone formation was assessed by measuring bone specific alkaline phosphatase (BSAP) and bone resorption by measuring urinary excretion of deoxypyridinoline (DPD) and N-telopeptide (NTX).

RESULTS: Between 11.6%-13.6% patients were osteoporotic (T score < -2.5) at the lumbar spine and/or hip. NTX levels were significantly higher in the patients with osteoporosis (P < 0.05) but BSAP and DPD levels were not significantly different. Independent risk factors for osteoporosis at either the lumbar spine or hip were a low body mass index (P < 0.001), increasing corticosteroid use (P < 0.005), and male sex (P < 0.01). These factors combined accounted for 23% and 37% of the reduction in BMD at the lumbar spine and hip respectively.

CONCLUSION: Our results confirm that osteoporosis is common in patients with CD and suggest that increased bone resorption is the mechanism responsible for the bone loss. However, less than half of the reduction in BMD can be attributed to risk factors such as corticosteroid use and low BMI and therefore remains unexplained.

Skeletal morbidity in inflammatory bowel disease

Patients with Crohn's disease are at increased risk of developing disturbances in bone and mineral metabolism because of several factors, including the cytokine-mediated nature of the inflammatory bowel disease, the intestinal malabsorption resulting from disease activity or from extensive intestinal resection and the use of glucucorticoids to control disease activity. Inability to achieve peak bone mass when the disease starts in childhood, malnutrition, immobilization, low BMI, smoking and hypogonadism may also play a contributing role in the pathogenesis of bone loss. The relationship between long-term use of glucocorticoids for any disease indication and increased risk for osteoporosis and fractures is well established. However, the relationship between Crohn's disease and ulcerative colitis and bone loss remains controversial. Depending on the population studied the prevalence of osteoporosis has thus been variably reported to range from 12 to 42% in patients with inflammatory bowel disease (IBD). In IBD most studies demonstrate a negative correlation between bone mineral density (BMD) and glucocorticoid use, but not all authors agree on the relationship between long-term glucocorticoid use and continuing bone loss. Whereas prospective studies do suggest sustained bone loss at both trabecular and cortical sites in long-term glucocorticoid users with inflammatory bowel disease, a decrease in bone mass is also observed in patients with active Crohn's disease not using glucocorticoids, and bone loss is not universally observed in patients with Crohn's disease using orally or rectally administered glucocorticoids. Data on vertebral fractures are scarce and there is no agreement about the risk of non-vertebral fractures in patients with Crohn's disease, although it has been suggested that non-vertebral fracture risk may be increased by up to 60% in patients with IBD. A recent publication reports an increased risk of hip fractures in Crohn's disease related to current and cumulative corticosteroid use and use of opiates, although these fractures could not be related to the severity of osteoporosis. The issue of the magnitude of the problem of osteoporosis has become particularly relevant in Crohn's disease, since the ability of therapeutic interventions to beneficially influence skeletal morbidity has been clearly established in patients with osteoporosis, whether post-menopausal women, men or glucocorticoid users. The main question that arises is whether all patients with Crohn's disease should be treated with bone protective agents on the assumption that they all have the potential to develop osteoporosis or whether the use of these agents should be restricted to patients clearly at risk of osteoporosis and fractures, providing these can be identified. We recommend, based on the available literature and our own experience, that all patients with Crohn's disease should be screened for osteoporosis by means of a bone mineral density measurement in addition to full correction of any potential calcium and vitamin D deficiency, to allow timely therapeutic intervention of the patient at risk while sparing the vast majority unnecessary medical treatment.

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

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

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

BACKGROUND

Osteoporosis is a common complication of Crohn's disease.

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

All patients with inflammatory bowel disease should have bone density assessment: pro

Bone loss is a common problem for individuals with inflammatory bowel disease. Corticosteroids play an important role in the development of osteoporosis in these patients; however, active disease and longer disease duration also appear to increase the risk of osteoporosis. Given the current burden of osteoporosis, bone mineral density is recommended.

Nutrition in inflammatory bowel disease

Recent developments concerning nutritional complications of inflammatory bowel disease include a better understanding of disease-associated anorexia and increasing recognition of the interaction of nutrition and cytokines in the pathogenesis of growth impairment of children. Decreased bone mineral density is a multifactorial complication and an increased focus of research. Enteral nutrition continues to play an important role in the therapy of Crohn's disease. The mechanisms whereby specific nutrients, such as n-3 fatty acids, antioxidants, and butyrate, ameliorate inflammation are being elucidated in in-vitro studies, but beneficial effects have yet to be translated into the clinical sphere.