Management of osteoporosis in patients with gastrointestinal diseases

Celiac Disease and Its Role in the Development of Metabolic Bone Disease

Celiac disease (CD) is an immune-mediated enteropathy that occurs in genetically susceptible hosts with the ingestion of gluten-containing products. Ongoing gluten consumption leads to intestinal damage, characterized by villous blunting and increased intraepithelial lymphocytes, resulting in malabsorption. Pertinent to the development of bone disease, malabsorption of calcium and vitamin D leads to secondary hyperparathyroidism and metabolic bone disease among individuals with CD. In this article, we review the pathogenesis of CD and the effects of malabsorption on bone health. Imbalances in bone resorption and formation particularly in individuals with CD and persistent disease activity ultimately lead to a state of bone loss and impaired mineralization. Initiation of a gluten-free diet is critical in the management of CD-related metabolic bone disease, demonstrating improvements in bone mineral density within the first year of dietary adherence.

Increased Risk of Osteoporotic Fracture in Postgastrectomy Gastric Cancer Survivors Compared With Matched Controls: A Nationwide Cohort Study in Korea

OBJECTIVES

Gastrectomy can lead to bone loss. Previous studies have suggested that there is an increased risk of fracture in gastric cancer survivors. However, these studies were performed without proper control groups. Therefore, we used Korean national health insurance data to compare the fracture risk in gastric cancer survivors who received gastrectomy to that of the general population.

METHODS

A total of 133,179 gastric cancer survivors were included and matched to noncancer controls using 1:1 propensity score matching. Cox proportional hazards regression analysis was used to determine the relative risk of fracture between the gastric cancer survivors and matched controls. We also examined the factors associated with fracture in gastric cancer survivors.

RESULTS

Compared with the matched controls, gastric cancer survivors had an elevated risk of osteoporotic fracture (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.53-1.70), which was most prominent in patients who underwent total gastrectomy (HR 2.18, 95% CI 1.96-2.44) and adjuvant chemotherapy (HR 2.01, 95% CI 1.81-2.23). In multivariate analysis, anemia was significantly associated with increased fracture risk (aHR 1.34, 95% CI 1.13-1.59), while decrease in weight >5% was not (aHR 1.06, 95% CI 0.89-1.25).

DISCUSSION

Gastric cancer survivors who underwent gastrectomy had an increased osteoporotic fracture risk than did matched controls. Total gastrectomy, adjuvant chemotherapy, and anemia were associated with an even higher risk in these patients. Additional studies are needed to establish optimal strategies, such as screening for osteoporosis and preventive interventions, that will reduce fracture risk in this population.

Use of pamidronate for osteoporosis treatment in public health care in Brazil

PURPOSE

The use of bisphosphonates for osteoporosis is effective in reducing the risk of fractures. However, oral formulations are sometimes not well tolerated or are contraindicated. Due to its availability in Brazilian public health system, pamidronate is frequently prescribed for osteoporosis, despite the lack of studies demonstrating its anti-fracture efficacy and the absence of FDA or EMEA approval for this purpose. The aim of this study was to evaluate the bone mineral density (BMD) response to pamidronate in a group of women with osteoporosis in a tertiary care hospital.

PATIENTS AND METHODS

The medical records of women with osteoporosis who received pamidronate for up to two years of treatment were reviewed. Patients were stratified at high or intermediate risk of fracture.

RESULTS

A total of 70 women were in treatment with pamidronate. Among them, 74% were at high risk of fracture. A significant gain in spine BMD after 24 months of treatment was observed (p=0.012). There was no difference between the groups of high and not high risk of fracture. At the femur, no significant increase in BMD was present, though, a strong negative correlation with high PTH levels (r=-0.61; p=0.003) was seen. In the multivariate analysis BMI at 12 months had impact in the response to the treatment.

CONCLUSION

The intravenous pamidronate in a group of postmenopausal women with predominant high risk of fracture promoted an isolated gain in the spine BMD, even though, clinical randomized trials are needed to confirm its anti-fracture efficacy.

Recombinant human growth hormone in the treatment of patients with cystic fibrosis

CONTEXT

Recombinant human growth hormone (rhGH) improves growth in patients with growth hormone deficiency or idiopathic short stature. Its role in patients with cystic fibrosis (CF) is unclear.

OBJECTIVE

To review the effectiveness of rhGH in the treatment of patients with CF.

METHODS

Medline and the Cochrane Central Register of Controlled Trials were searched from the earliest date through April 2010. Randomized controlled trials, observational studies, systematic reviews/meta-analyses, or case reports were included if rhGH therapy was administered to patients with CF and data on prespecified harms, intermediate outcomes, or final health outcomes were reported. When applicable, end points were pooled by using a random-effects model. The overall body of evidence was graded for each outcome as insufficient, low, moderate, or high.

RESULTS

Ten unique controlled trials (n = 312) and 8 observational studies (n = 58) were included. On quantitative synthesis of controlled trials, several markers of pulmonary function, anthropometrics, and bone mineralization were significantly improved versus control. Results of single-arm observational studies for the aforementioned outcomes were generally supportive of findings in clinical trials. There is insufficient evidence to determine the effect of rhGH on intravenous antibiotic use during therapy, pulmonary exacerbations, health-related quality-of-life, bone consequences, or total mortality, but moderate evidence suggests that rhGH therapy reduces the rate of hospitalization versus control.

CONCLUSIONS

rhGH improved almost all intermediate measures of pulmonary function, height, and weight in patients with CF. Improvements in bone mineral content are also promising. However, with the exception of hospitalizations, the benefits on final health outcomes cannot be directly determined at this time.

Skeletal sequelae of cancer and cancer treatment

INTRODUCTION

Survivors of cancer may experience lingering adverse skeletal effects such as osteoporosis and osteomalacia. Skeletal disorders are often associated with advancing age, but these effects can be exacerbated by exposure to cancer and its treatment. This review will explore the cancer and cancer treatment-related causes of skeletal disorders.

METHODS

We performed a comprehensive search, using various Internet-based medical search engines such as PubMed, Medline Plus, Scopus, and Google Scholar, for published articles on the skeletal effects of cancer and cancer therapies.

RESULTS

One-hundred-forty-two publications, including journal articles, books, and book chapters, met the inclusion criteria. They included case reports, literature reviews, systematic analyses, and cohort reports. Skeletal effects resulting from cancer and cancer therapies, including hypogonadism, androgen deprivation therapy, estrogen suppression, glucocorticoids/corticosteroids, methotrexate, megestrol acetate, platinum compounds, cyclophosphamide, doxorubicin, interferon-alpha, valproic acid, cyclosporine, vitamin A, NSAIDS, estramustine, ifosfamide, radiotherapy, and combined chemotherapeutic regimens, were identified and described. Skeletal effects of hyperparathyroidism, vitamin D deficiency, gastrectomy, hypophosphatemia, and hyperprolactinemia resulting from cancer therapies were also described.

DISCUSSION/CONCLUSIONS

The publications researched during this review both highlight and emphasize the association between cancer therapies, including chemotherapy and radiotherapy, and skeletal dysfunction.

IMPLICATIONS FOR CANCER SURVIVORS

These studies confirm that cancer survivors experience a more rapid acceleration of bone loss than their age-matched peers who were never diagnosed with cancer. Further studies are needed to better address the skeletal needs of cancer survivors.

[Case report: recently diagnosed celiac disease as aggravating factor of osteoporosis in an old woman]

Sixty-three-year-old woman requested medical attention for osteoporosis. Bone densitometry revealed: T(spine (L1-L4))= -3.5 SD [Bone mineral density (BMD): 0.766 g/cm(2)]. T(femoral neck) = -2.4 SD (BMD: 0.716 g/cm(2)). She has been in calcium and vitamin D supplementation for 2 years. She informed a 5-year-history of hypothyroidism in levothyroxine replacement. Alendronate sodium 70 mg/week was initiated with significant increase in BMD in the first year (6.1% equally in spine and femoral neck). After a 5-year follow-up, the patient presented with weight loss, anemia and decrease in BMD (12.6% in spine and 20.9% in femoral neck). Clinical history revealed intermittent diarrhea episodes for 2 years and the hypothesis of celiac disease was suspected. Anti-gliadin and anti-endomysium antibodies were positive: 25.3 U/mL (< 20) e 1/5 U/mL (RV: negative), respectively. Bone biochemical parameters revealed normal levels of calcium and phosphate, increased parathyroid hormone: 283 pg/mL (10-65) and increased levels of bone reabsortion markers, consistent with secondary hyperparathyroidism in response to malabsorptive syndrome. One year after gluten-free diet, patient improved of malabsorptive symptoms and gained BMD (47.3% in spine and 31.6% in femoral neck), confirming the hypothesis of celiac disease as aggravating factor of osteoporosis in this patient.

Vitamin D insufficiency/deficiency in gastrointestinal disorders

Vitamin D and calcium are critical for skeletal health. Their absorption from the intestine is negatively impacted by a number of gastrointestinal diseases and surgical procedures, leading to osteoporosis and/or osteomalacia. Diseases of the liver can impact the metabolism of vitamin D to its circulating form, 25(OH)D, as well as the production of carrier proteins, albumin and vitamin D-binding protein, that may alter the delivery of 25(OH)D and its active metabolite 1,25(OH)(2)D to target tissues, including the skeleton, again leading to bone disease. The clinician evaluating a patient with apparent osteoporosis and vitamin D deficiency/ insufficiency needs to consider a gastrointestinal etiology. Similarly, the clinician evaluating a patient with a gastrointestinal disorder needs to evaluate that patient for vitamin D deficiency and bone disease. Treatment involves adequate vitamin D and calcium supplementation to achieve normal serum 25(OH)D, PTH, and serum and urine calcium levels.

African-American women: health beliefs, lifestyle, and osteoporosis

Cultural beliefs of African-American women, manifested in lifestyle behaviors, may influence osteoporosis development. Genetics may have a positive influence on bone density, but the risks increase from other diseases that may contribute to the development of secondary osteoporosis. Health beliefs, lifestyle behaviors, and secondary osteoporosis causes are explored, focusing on relationships with osteoporosis. African-American women must be informed of the risks involved with some of the traditional health beliefs and practices. Healthcare providers have a challenge and responsibility to explore cultural beliefs with African-American women and to develop an acceptable approach to osteoporosis prevention.

Metabolic bone disease in gastrointestinal illness

Metabolic bone disease is often silent, often undiagnosed, and occurs frequently in patients with chronic gastrointestinal illnesses. Potentially modifiable risk factors, such as malnutrition, malabsorption, prolonged use of glucocorticoids, and a sedentary lifestyle, can lead to low bone mass, an increased rate of bone loss, and debilitating bone disease. This article explores common gastrointestinal illnesses that place patients at risk for developing metabolic bone disease. Concepts are presented to assist the practitioner in identifying patients at risk; clinical evaluation and diagnostic test selection are discussed, and therapeutic options for the prevention and treatment of metabolic bone disease in gastrointestinal illness are presented.

Vicious circles in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease can present with a bewildering array of disease manifestations whose overall impact on patient health is difficult to disentangle. The multitude of disease complications and therapeutic side effects result in conflicting ideas on how to best manage a patient. The aim of the study is to test the usefulness of influence diagrams in resolving conflicts centered on managing complex disease processes.

METHODS

The influences of a disease process and the ensuing medical interventions on the health of a patient with inflammatory bowel disease are modeled by an influence diagram. Patient health is the focal point of multiple influences affecting its overall strength. Any downstream influence represents the focal point of other preceding upstream influences. The mathematics underlying the influence diagram is similar to that of a decision tree. Its formalism allows one to consider additive and inhibitory influences and include in the same analysis qualitatively different types of parameters, such as diagnoses, complications, side effects, and therapeutic outcomes.

RESULTS

Three exemplary cases are presented to illustrate the potential use of influence diagrams. In all three case scenarios, Crohn's disease resulted in disease manifestations that seemingly interfered with its own therapy. The presence of negative feedback loops rendered the management of each case particularly challenging. The analyses by influence diagrams revealed subtle interactions among the multiple influences and their joint contributions to the patient's overall health that would have been difficult to appreciate by verbal reasoning alone.

CONCLUSION

Influence diagrams represent a decision tool that is particularly suited to improve decision-making in inflammatory bowel disease. They highlight key factors of a complex disease process and help to assess their quantitative interactions.

The role of surgery in patients with advanced gastric cancer

Surgery remains the mainstay of treatment with curative intent for established gastric cancer. Patient selection is critical to achieving satisfactory outcomes, and involves careful assessment of both patient fitness and disease stage. Staging techniques have multiplied and become much more sensitive in recent years. Current best practice involves a combination of spiral CT scan, Endoscopic ultrasound, PET scanning and laparoscopy. Only a minority of patients progress to potentially curative surgery after staging and fitness assessment in Western centres. Conventional treatment involves a distal subtotal gastrectomy or total gastrectomy depending on the site of the lesion. Innovative techniques include the Merendino operation, and pylorus and nerve sparing gastrectomies for earlier stage disease in the proximal and distal stomach, respectively. There is evidence of nutritional and quality of life benefit in the first 2 years after surgery from formation of a gastric substitute reservoir. Laparoscopic resection is well established in Japan and is developing rapidly elsewhere but its role and outcomes are not yet well defined. Radical lymph node dissection remains controversial: randomised trial evidence of overall benefit is lacking, but expert series have produced excellent results, and there are indications of a sub-group benefit for patients with stage II and III disease. The increased morbidity and mortality associated with radical dissection appear to be largely attributable to pancreatic and splenic resection together with limitations in Unit expertise. Surgical palliation has become less important in recent years as interventional radiology and endoscopy techniques have been developed for the same purposes. Overall mortality and survival results have improved dramatically over the last 20 years, but interpretation of these figures is made difficult by major changes in staging and case selection. The chances of long-term survival are, however, clearly much greater, and those of peri-operative death much less for an individual patient accepted for surgery in 2006 than they would have been in 1986.

Bone loss in Crohn's disease: exercise as a potential countermeasure

Crohn's disease (CD) is associated with a number of secondary conditions including osteoporosis, which increases the risk of bone fracture. The cause of metabolic bone disease in this population is believed to be multifactorial and may include the disease itself and associated inflammation, high-dose corticosteroid use, weight loss and malabsorption, a lack of exercise and physical activity, and an underlying genetic predisposition to bone loss. Reduced bone mineral density has been reported in between 5% to 80% of CD sufferers, although it is generally believed that approximately 40% of patients suffer from osteopenia and 15% from osteoporosis. Recent studies suggest a small but significantly increased risk of fracture compared with healthy controls and, perhaps, sufferers of other gastrointestinal disorders such as ulcerative colitis. The role of physical activity and exercise in the prevention and treatment of CD-related bone loss has received little attention, despite the benefits of specific exercises being well documented in healthy populations. This article reviews the prevalence of and risk factors for low bone mass in CD patients and examines various treatments for osteoporosis in these patients, with a particular focus on physical activity.

Rapid improvement of bone metabolism after infliximab treatment in Crohn's disease

BACKGROUND

Crohn's disease is associated with low bone mineral density and altered bone metabolism.

AIM

To assess the evolution of bone metabolism in Crohn's disease patients treated with infliximab.

METHODS

We studied 71 Crohn's disease patients treated for the first time with infliximab for refractory Crohn's disease. Biochemical markers of bone formation (type-I procollagen N-terminal propeptide, bone-specific alkaline phosphatase, osteocalcin) and of bone resorption (C-telopeptide of type-I collagen) were measured in the serum before and 8 weeks after infliximab therapy and compared with values in a matched healthy control group.

RESULTS

Eight weeks after treatment with infliximab, a normalization of bone markers was observed with a median increase in formation markers of 14-51% according to marker and a lower but significant decrease in resorption marker (median 11%). A clinically relevant increase in bone formation markers was present in 30-61% of patients according to the marker. A clinically relevant decrease in C-telopeptide of type-I collagen was present in 38% of patients. No association was found with any tested demographic or clinical parameter.

CONCLUSION

Infliximab therapy in Crohn's disease may rapidly influence bone metabolism by acting either on bone formation or bone resorption. This improvement seems to be independent of clinical response to infliximab.