Prevention and treatment of osteoporosis in inflammatory bowel disease

Health Care Maintenance in Patients with Crohn's Disease

Health care maintenance is critical for patients with inflammatory bowel disease (IBD), particularly for those receiving immunosuppressive medications. Vaccination recommendations for potentially preventable diseases, cancer prevention recommendations, and assessment of bone health and mood disorders are discussed in this article. Staying up to date with health care maintenance is of utmost importance, and all gastroenterologists caring for patients with IBD should be able to make recommendations regarding preventative care of these patients.

Health Maintenance for Adult Patients with Inflammatory Bowel Disease

PURPOSE OF REVIEW

This review serves as a summary of healthcare maintenance items that should be addressed when managing patients with inflammatory bowel disease (IBD). This manuscript discusses vaccine-preventable illnesses, cancer prevention recommendations, and other screenings that are important to gastroenterologists and primary care physicians caring for patients with IBD.

RECENT FINDINGS

Patients with IBD often require immunomodulator agents and/or biologics to induce and maintain disease remission which can increase the risk of developing several infections. Also, subsets of patients with IBD are at an increased risk for a number of malignancies including colon, cervical, and skin cancers.

SUMMARY

Staying up-to-date with health care maintenance of patients with IBD is critical, especially given their increased risk for vaccine-preventable infections as well as comorbidities such as cancers, bone health, and mood disorders. Gastroenterologists and primary care physicians should familiarize themselves with the required screenings and vaccines that are recommended for adult patients with IBD, particularly those who are immunosuppressed.

Incidence and risk factors of micronutrient deficiency in patients with IBD and intestinal Behçet's disease: folate, vitamin B12, 25-OH-vitamin D, and ferritin

BACKGROUND

Patients with inflammatory bowel disease (IBD) and intestinal Behçet's disease (BD) are vulnerable to micronutrient deficiencies due to diarrhea-related gastrointestinal loss and poor dietary intake caused by disease-related anorexia. However, few studies have investigated the incidence and risk factors for micronutrient deficiency.

METHODS

We retrospectively analyzed 205 patients with IBD who underwent micronutrient examination, including folate, vitamin B12, 25-OH-vitamin D, and/or ferritin level quantification, with follow-up blood tests conducted 6 months later.

RESULTS

Eighty patients (39.0%), who were deficient in any of the four micronutrients, were classified as the deficiency group, and the remaining 125 (61.0%) were classified as the non-deficient group. Compared to those in the non-deficiency group, patients in the deficiency group were much younger, had more Crohn's disease (CD) patients, more patients with a history of bowel operation, and significantly less 5-amino salicylic acid usage. Multivariate analysis revealed that CD and bowel operation were significant independent factors associated with micronutrient deficiency.

CONCLUSIONS

The incidence of micronutrient deficiency was high (39.0%). Factors including CD, bowel operation, and younger ages were found to be associated with higher risks of deficiency. Therefore, patients with IBD, especially young patients with CD who have undergone bowel resection surgery, need more attention paid to micronutrition.

Inflammatory Bowel Disease in the Older Adult

Although management of inflammatory bowel disease follows a similar approach for all adults, there are certain characteristics making its treatment more challenging in older patients. The advent of novel medical treatments has changed the paradigm of inflammatory bowel disease, with an increasing focus on preventing disease progression in addition to controlling symptoms. The safety of these therapies in the elderly needs to be considered. Management of inflammatory bowel disease in the elderly is confounded by comorbidities that can increase the risk of medication or surgical complications; polypharmacy and altered pharmacokinetics also increase the risk of drug-drug interactions and adverse events.

Elderly-onset vs adult-onset ulcerative colitis: a different natural history?

Background

Incidence of ulcerative colitis (UC) in elderly population is increasing because of ageing and because of its minimal impact on life span. Data on natural history, outcomes and therapeutic strategies are limited.

Our aim is to characterize UC in elderly-onset patients followed at our Inflammatory Bowel Disease outpatient clinic and compare with adult-onset UC.

Methods

From January 2000 to June 2019, 94 patients with UC diagnosed after the age of 65 years (elderly group, E-O) were identified and matched 1–1 according to gender and calendar year of diagnosis with patients diagnosed with UC at age between 40 and 64 years (adult age, A-O).

Results

Comorbidity Index (3.8 vs 1.6, p < 0.0005) was higher for elderly UC patients. Symptoms at presentation were similar between the two groups, although abdominal pain was more common in adults, and weight loss was more common in the elderly. At diagnosis, left colitis (61% vs 39%) and proctitis (14% vs 26%) (p = 0.011) were more frequent in the elderly. Therapy and clinical behaviour were similar. Surgery was more frequently performed in the elderly (20% vs 9%, p = 0.02), while biological therapy was less used (2.1% vs 22%, p < 0.0005). Complications were more frequent in the elderly. Extraintestinal manifestations were lower in elderly patients (9.6% vs 19.2%, p = 0.061). Time to first relapse was similar between the two groups. Mortality (p < 0.0005) was higher in elderly patients.

Conclusions

Ulcerative Colitis has similar presentation and behaviour in elderly and adults patients. However, the elderly are more fragile because of comorbidities, increased risk of infections and disease-related complications.

Self-Prescribed Dietary Restrictions are Common in Inflammatory Bowel Disease Patients and Are Associated with Low Bone Mineralization

Background and objectives: Despite the serious concerns of patients about the role of food in triggering or ameliorating their intestinal disease, there are few studies dealing with patients’ beliefs and practices regarding diet in inflammatory bowel disease (IBD). The aim of this study was to investigate how the disease affected the dietary habits of patients with IBD, and to assess if patients’ food restrictions were responsible for low bone mineralization. Materials and Methods: For this study, 90 consecutive patients referred for IBD were interviewed regarding their dietary habits. Demographic features and clinical characteristics potentially associated with the dietary habits were collected. A validated and self-administered survey questionnaire dealing with dietary habits and patients’ beliefs and perceptions regarding food was analyzed. Multivariate logistic regression analysis was performed in order to identify risk factors for dietary restrictions among participants and to evaluate the relationship between dietary restrictions and low bone mineral density (BMD). Results: Among the 63 (70%) patients who claimed a self-prescribed dietary restriction, 84% avoided dairy products. Significant risk factors (adjusted odds ratio (OR), 95% confidence interval (CI)) for the dietary restrictions were a younger age (p = 0.02), a higher level of education (p = 0.007), and a higher visceral sensitivity index (p = 0.009). Most (80%) of the patients displayed an inadequate calcium intake, and an abnormal result at dual-energy X-ray absorptiometry (DXA) scan accounting for low BMD was reported in 46 (51%) of them. Dietary restrictions (p = 0.03), and in particular avoiding dairy products (p = 0.001), were significant risk factors for a low BMD, along with female gender (p = 0.001), smoking (p = 0.04), and steroid abuse (p = 0.03). Almost all (86%) patients changed their diet after IBD diagnosis, as 8% believed that foods could have been a trigger for IBD and 37% that a proper diet was more important than drugs in controlling disease. Although 61% of the patients claimed to have received nutritional advice, 78% of the participants showed interest in receiving more. Conclusions: Dietary habits of IBD patients should be investigated by healthcare professionals as part of the routine visit. Clinicians are invited to provide nutritional recommendations to these patients in order to avoid unnecessary self-prescribed dietary restrictions.

Does the Antitumor Necrosis Factor-α Therapy Decrease the Vertebral Fractures Occurrence in Inflammatory Bowel Disease?

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.

The effects of dihydroartemisinin on inflammatory bowel disease-related bone loss in a rat model

Bone loss is one of the important extra-intestinal manifestations in patients with inflammatory bowel diseases (IBDs). Compounds derived from natural products have been used to treat IBDs. However, the role of natural products on IBD-induced bone loss is not completely clarified. In the present study, we observed the effects of dihydroartemisinin (DHA), an antimalaria drug, on IBD and IBD-induced bone loss in a rat model. Chronic IBD model was established in Sprague-Dawley rats by giving them 2.5% dextran sodium sulfate in drinking water. DHA was given by intraperitoneal injection. Blood, colon, and bone samples were collected for biomarker assay and histological analysis. There was an obvious increase in tumor necrotic factor (TNF) α and receptor activator of nuclear factor (NF)-kB ligand (RANKL), and decrease in procollagen type 1 N-terminal propeptide (P1NP) level in IBD groups compared with the normal control (p < 0.05). The disease activity score of IBD rats was significantly higher than the control (p < 0.01). Obvious decrease in disease activity score, TNFα, and RANKL level and increase in P1NP were observed in DHA-treated IBD rats. Bone loss, shown as the decrease in bone mineral density, bone volume fraction, and trabecular number and increase in trabecular separation were observed in IBD rats compared with control (p < 0.01). DHA treatment obviously abolished the bone loss, in particular in the high-dose group (p < 0.05). DHA treatment also inhibited the excessive osteoclast formation; RANKL protein expression; and RANK, TRAF6, Fra-1, NFATc1 mRNA expression induced by IBD. Our data indicated that DHA may be a potential therapeutic agent for IBD and IBD-induced bone loss. Impact statement Bone loss is one of the important extra-intestinal manifestations in patients with inflammatory bowel diseases (IBDs). Studies have shown that compounds derived from natural products are useful in the treatment of IBDs. However, few studies have investigated the role of compounds derived from natural products in treatment of osteoporosis in IBDs. The current study aimed to show the effects of dihydroartemisinin (DHA), antimalaria drug, on bone loss in a rat model of IBD. The findings showed that DHA intervention dose dependently protected against bone loss in IBD rats by inhibiting tumor necrotic factor α production and osteoclast formation. These findings highlights that DHA may be beneficial for bone health in those patients with IBD.

Health Maintenance Documentation Improves for Veterans with IBD Using a Template in the Computerized Patient Record System

BACKGROUND

Inflammatory bowel diseases (IBD) and the therapies used to treat these conditions can lead to preventable complications. In 2011, AGA developed the Adult IBD Physician Performance Measures Set to improve accountability and performance management in IBD care; however, compliance remains poor.

AIM

The aim of this study is to assess for an improvement in provider compliance with the recommended outpatient preventive care measures in our VA IBD patients after July 2014 following the implementation of a health maintenance template in the Computerized Patient Record system (CPRS).

METHODS

We conducted a single-center, retrospective chart review of 139 IBD patients with at least one visit before and after the implementation of the health maintenance template through November 2016. We collected demographic data, immunosuppressive medication use, and recommendations for preventive care. For each variable analyzed, we included those patients where the preventive care measure was indicated based on age, gender, and/or medication use. The McNemar's test for paired nominal data was used to assess the significant difference in recommendation rate, pre- versus post-template implementation. A p value of < 0.05 was considered significant.

RESULTS

We included 139 patients (46% with Crohn's disease, 53% with ulcerative colitis, 1% with indeterminate colitis) in the analysis. Seventy-eight (56%) patients were on immunosuppressants. All preventive care measures significantly improved after implementation of the CPRS template except for HPV vaccination.

CONCLUSIONS

Implementing a health maintenance template in outpatient GI clinic notes significantly improved provider documentation of the recommended outpatient preventive care in our VA IBD population.

Treatment of Inflammatory Bowel Disease in the Older Patient

The incidence of inflammatory bowel disease (IBD) is increasing, and as our population ages, there is a growing number of IBD patients who are transitioning into advanced age; 15% to 20% of IBD patients are classified as late-onset (between 60-65 years of age). This has led clinicians to treat a large number of older patients with IBD. The principles of management of IBD in older patients are the same as those who are younger. There are, however, phenotypic differences that are unique to late-onset IBD and age-related concerns that clinicians must consider when initiating therapy for their older patients with IBD. Given the increasing number of older IBD patients, the aim of this article is to present an updated, evidence-based review of the therapeutic options and issues that arise in this unique patient population.

Management of inflammatory bowel disease in older persons: evolving paradigms

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing, and considering the aging population, this number is set to increase further in the future. The clinical features and natural history of elderly-onset IBD have many similarities with those of IBD in younger patients, but with significant differences including a broader differential diagnosis. The relative lack of data specific to elderly patients with IBD, often stemming from their typical exclusion from clinical trials, has made clinical decision-making somewhat challenging. Treatment decisions in elderly patients with IBD must take into account age-specific concerns such as comorbidities, locomotor and cognitive function, and polypharmacy, to set realistic treatment targets in order to enable personalized treatment and minimize harm. Notwithstanding paucity of clinical data, recent studies have provided valuable insights, which, taken together with information gleaned from previous studies, can broaden our understanding of IBD. These insights may contribute to the development of paradigms for the holistic and, when possible, evidence-based management of this potentially vulnerable population and are the focus of this review.

Health Maintenance in Inflammatory Bowel Disease

PURPOSE OF REVIEW

Patients with inflammatory bowel disease (IBD) are not receiving preventative care services at the same rate as the general population. IBD patients are at increased risk for infections, osteoporosis, and certain malignancies secondary to their disease and as they are on immunosuppressive therapy. They are a younger population and often times consider their gastroenterologist as their primary care physician. In this review, we discuss up-to-date evidence pertaining to vaccine-preventable illnesses in the immunosuppressed IBD patient, screening for bone health, cervical cancer, skin malignancies, psychological wellbeing, and smoking cessation.

RECENT FINDINGS

Vaccinations are recommended in the IBD population as they are immunosuppressed and at increased risk for acquiring influenza and pneumonia. Not only are they at greater risk to acquire it but they also have a much severe complicated course. Ideally, IBD patients should be vaccinated prior to initiating immunosuppression and most inactive vaccines can be administered to them while they are on therapy. All IBD patients should be encouraged to stop smoking and have adequate vitamin D intake along with appropriate applicable cancer screenings. Gastroenterologists must work in collaboration with primary care providers along with other specialists to help provide our patients well-rounded care for their IBD.

Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study

Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care.

Elderly patients and inflammatory bowel disease

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing globally. Coupled with an ageing population, the number of older patients with IBD is set to increase. The clinical features and therapeutic options in young and elderly patients are comparable but there are some significant differences. The wide differential diagnosis of IBD in elderly patients may result in a delay in diagnosis. The relative dearth of data specific to elderly IBD patients often resulting from their exclusion from pivotal clinical trials and the lack of consensus guidelines have made clinical decisions somewhat challenging. In addition, age specific concerns such as co-morbidity; loco-motor and cognitive function, poly-pharmacy and its consequences need to be taken into account. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this vulnerable group and set appropriate boundaries maximising benefit and minimising harm. Meanwhile, clinicians need to make personalised decisions but as evidence based as possible in the holistic, considered and optimal management of IBD in elderly patients. In this review we will cover the clinical features and therapeutic options of IBD in the elderly; as well as addressing common questions and challenges posed by its management.

The bone and fat connection in inflammatory bowel diseases

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.

Are maintenance strategies underused in Crohn's disease?

A key aim in the management of Crohn's disease is to maintain disease remission, whether this has been achieved by medical or surgical treatment. The reasons for doing this are to maintain quality of life, to avoid steroid dependence and to maintain mucosal healing with a view to preventing relapse, hospital admission and surgery, and improving disease natural history. Options for remission maintenance include smoking cessation, thiopurines, methotrexate, anti-TNF-α drugs and surgery. Evidence suggests that in some places now, and in most places in the past, too few patients are/were appropriately treated when in remission, and, in many instances, treatment regimens are/were insufficiently tailored to the patient's individual phenotype, prognosis and/or genotype.

Defining quality indicators for best-practice management of inflammatory bowel disease in Canada

BACKGROUND

There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management.

METHODS

The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members.

RESULTS

Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy.

CONCLUSIONS

These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.

Vitamin D levels and bone metabolism in Chinese adult patients with inflammatory bowel disease

OBJECTIVE

We aimed to investigate the serum 25-hydroxyvitamin D3 (25[OH]D3 ) levels and bone metabolism in adult Chinese patients with inflammatory bowel disease (IBD) and to evaluate the correlation between vitamin D levels and the disease activity as well as the potential risk factors.

METHODS

Age- and gender-matched cohort of IBD patients (124 with ulcerative colitis [UC] and 107 with Crohn's disease [CD]) and 122 healthy controls were enrolled in this study. Serum levels of 25(OH)D3 and bone mineral density (BMD) were measured, and the correlation between the two parameters and the severity of the disease as well as the clinical risk factors were analyzed.

RESULTS

Serum 25(OH)D3 levels were lower in UC (10.32 ± 4.46 ng/mL, P < 0.001) and CD patients (11.57 ± 5.02 ng/mL, P = 0.029) than that in healthy controls (12.87 ± 4.40 ng/mL). 25(OH)D3 levels were negatively correlated with the disease severity of both UC (r = -0.371, P < 0.001) and CD (r = -0.285, P = 0.030). The incidences of osteopenia and osteoporosis were high in the IBD patients (37.9% and 3.2% in UC and 30.8% and 4.7% in CD, respectively). Cumulative quantity of glucocorticoids use was significantly associated with osteopenia and osteoporosis in both UC (odds ratio [OR] 1.219, 95% confidence interval [CI] 1.054-1.410, P = 0.008) and CD patients (OR 1.288, 95% CI 1.033-1.606, P = 0.025).

CONCLUSIONS

Vitamin D deficiency is likely to occur in Chinese patients with IBD and is closely associated with the severity of the disease. Glucocorticoids accumulation is a risk factor for osteopenia and osteoporosis.

Systematic review with meta-analysis: inflammatory bowel disease in the elderly

BACKGROUND

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.

AIM

To critically review available data regarding the care of elderly IBD patients.

METHODS

Bibliographic searches (MEDLINE) up to June 2013.

RESULTS

Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.

CONCLUSIONS

Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

Increased fracture risk assessed by fracture risk assessment tool in Greek patients with Crohn's disease

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.

Micronutrient deficiencies in inflammatory bowel disease: from A to zinc

Inflammatory bowel disease (IBD) has classically been associated with malnutrition and weight loss, although this has become less common with advances in treatment and greater proportions of patients attaining clinical remission. However, micronutrient deficiencies are still relatively common, particularly in CD patients with active small bowel disease and/or multiple resections. This is an updated literature review of the prevalence of major micronutrient deficiencies in IBD patients, focusing on those associated with important extraintestinal complications, including anemia (iron, folate, vitamin B12) bone disease (calcium, vitamin D, and possibly vitamin K), hypercoagulability (folate, vitamins B6, and B12), wound healing (zinc, vitamins A and C), and colorectal cancer risk (folate and possibly vitamin D and calcium).

Health maintenance in the inflammatory bowel disease patient

Gastroenterologists are in a unique position to make very positive differences in the lives of their IBD patients. We understand that IBD patients do not receive preventive services at the same rate as general medical patients. Because these individuals are at increased risk for complications from preventable diseases, we have a valuable opportunity to protect this population (Table 1). Establishing a close working relationship with PCPs can facilitate delivering quality care, but it is important to note that some of these patients rely solely on their GI clinician for the majority of their care. In such a vulnerable population, it is important to be aggressive with vaccine recommendations, monitoring for depression, tobacco cessation, and in performing the appropriate cancer screening examinations. As professional societies and health care system increase their focus on quality measures, incorporating these important issues into routine practice will ultimately result in addressing quality standards; perhaps more important, it should provide our patients with the best individual care possible.

Low body mass index can identify majority of osteoporotic inflammatory bowel disease patients missed by current guidelines

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at high risk of developing osteoporosis. Our objective was to determine the usefulness of IBD guidelines in identifying patients at risk for developing osteoporosis.

METHODS

We utilized institutional repository to identify patients seen in IBD center and extracted data on demographics, disease history, conventional, and nonconventional risk factors for osteoporosis and Dual Energy X-ray Absorptiometry (DXA) findings.

RESULTS

59% of patients (1004/1703) in our IBD cohort had at least one risk factor for osteoporosis screening. DXA was documented in 263 patients with indication of screening (provider adherence, 26.2%), and of these, 196 patients had DXA completed ("at-risk" group). Ninety-five patients not meeting guidelines-based risk factors also had DXA completed ("not at-risk" group). 139 (70.9%) patients in "at-risk" group had low BMD, while 51 (53.7%) of "not-at-risk" patients had low BMD. Majority of the patients with osteoporosis (83.3%) missed by the current guidelines had low BMI. Multivariate logistic regression analysis showed that low BMI was the strongest risk factor for osteoporosis (OR 3.07; 95% CI, 1.47-6.42; P = 0.003).

CONCLUSIONS

Provider adherence to current guidelines is suboptimal. Low BMI can identify majority of the patients with osteoporosis that are missed by current guidelines.

Management of inflammatory bowel disease with vitamin D: beyond bone health

A relationship between vitamin D and several disorders, including Crohn's disease (CD), has recently been proposed. Vitamin D appears to have several important actions beyond the maintenance of bone health, including various effects on the immune system. Vitamin D deficiency has been implicated in the development of CD, and its analogues may have a role in the treatment of CD. Current research also suggests a role for vitamin D in counteracting some IBD-specific complications, including osteopenia, colorectal neoplasia, and depression. There remains a need for prospective studies to further delineate these relationships. Given current evidence and the apparent safety of vitamin D supplementation, it appears reasonable to screen for and treat vitamin D deficiency in patients with IBD.

Association of a common vitamin D-binding protein polymorphism with inflammatory bowel disease

OBJECTIVE

Inflammatory bowel diseases (IBDs), Crohn's disease, and ulcerative colitis (UC), are multifactorial disorders, characterized by chronic inflammation of the intestine. A number of genetic components have been proposed to contribute to IBD pathogenesis. In this case-control study, we investigated the association between two common vitamin D-binding protein (DBP) genetic variants and IBD susceptibility. These two single nucleotide polymorphisms (SNPs) in exon 11 of the DBP gene, at codons 416 (GAT>GAG; Asp>Glu) and 420 (ACG>AAG; Thr>Lys), have been previously suggested to play roles in the etiology of other autoimmune diseases.

METHODS

Using TaqMan SNP technology, we have genotyped 884 individuals (636 IBD cases and 248 non-IBD controls) for the two DBP variants.

RESULTS

On statistical analysis, we observed that the DBP 420 variant Lys is less frequent in IBD cases than in non-IBD controls (allele frequencies, P=0.034; homozygous carrier genotype frequencies, P=0.006). This inverse association between the DBP 420 Lys and the disease remained significant, when non-IBD participants were compared with UC (homozygous carrier genotype frequencies, P=0.022) or Crohn's disease (homozygous carrier genotype frequencies, P=0.016) patients separately. Although the DBP position 416 alone was not found to be significantly associated with IBD, the haplotype DBP_2, consisting of 416 Asp and 420 Lys, was more frequent in the non-IBD population, particularly notably when compared with the UC group (Odds ratio, 4.390).

CONCLUSION

Our study adds DBP to the list of potential genes that contribute to the complex genetic etiology of IBD, and further emphasizes the association between vitamin D homeostasis and intestinal inflammation.

Inflammatory bowel disease of the elderly: frequently asked questions (FAQs)

The growing recognition of the older inflammatory bowel disease (IBD) patient is heightened by the entry of the 77.2 million baby boomers who will turn 65 beginning of 2011. It is anticipated that this will occur at a rate of 10,000 per day or 4 million per year for the next 19 years. The management of IBD in this population is complex because of problems with co-morbidities, polypharmacy, impaired mobility, and cognition, as well as difficult social and financial issues. This review focuses on the older IBD patient's unique concerns and provides guidance in their diagnosis and management.

Long-term management of the liver transplant recipient: pearls for the practicing gastroenterologist

Liver transplantation is becoming more common and patients are surviving longer after transplantation. Special care must be paid to the long-term management of these patients because they are at increased risk for medical problems, malignancies, and adverse effects from immunosuppression. A stable and continuing relationship must be developed between the physician and the patient to optimize the long-term outcomes for these individuals.

Old-age inflammatory bowel disease onset: A different problem?

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

Advances in the understanding of mineral and bone metabolism in inflammatory bowel diseases

Chronic inflammatory disorders such as inflammatory bowel diseases (IBDs) affect bone metabolism and are frequently associated with the presence of osteopenia, osteoporosis, and increased risk of fractures. Although several mechanisms may contribute to skeletal abnormalities in IBD patients, inflammation and inflammatory mediators such as TNF, IL-1β, and IL-6 may be the most critical. It is not clear whether the changes in bone metabolism leading to decreased mineral density are the result of decreased bone formation, increased bone resorption, or both, with varying results reported in experimental models of IBD and in pediatric and adult IBD patients. New data, including our own, challenge the conventional views, and contributes to the unraveling of an increasingly complex network of interactions leading to the inflammation-associated bone loss. Since nutritional interventions (dietary calcium and vitamin D supplementation) are of limited efficacy in IBD patients, understanding the pathophysiology of osteopenia and osteoporosis in Crohn's disease and ulcerative colitis is critical for the correct choice of available treatments or the development of new targeted therapies. In this review, we discuss current concepts explaining the effects of inflammation, inflammatory mediators and their signaling effectors on calcium and phosphate homeostasis, osteoblast and osteoclast function, and the potential limitations of vitamin D used as an immunomodulator and anabolic hormone in IBD.

Biologic therapy and its effect on skeletal development in children with chronic inflammation

Chronic inflammatory conditions in children such as juvenile idiopathic arthritis, inflammatory bowel disease, cystic fibrosis and systemic lupus erythematosus can cause reduced linear growth, final height and bone mass. There are many mechanisms leading to these skeletal alterations but inflammation itself is considered to play an important role. Biologic therapy is being used increasingly for the treatment of chronic inflammatory conditions and may also be effective in improving growth and skeletal development. The main aim of this article is to summarize the effects of inflammation on growth and skeletal development and evaluate the effects of biologic therapy on growth and skeletal development in children with chronic inflammatory conditions.

Lower gastrointestinal bleeding in the elderly

Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management

Abstract Extraintestinal manifestations occur rather frequently in inflammatory bowel disease (IBD), e.g. ulcerative colitis (UC) and Crohn's disease (CD). The present paper provides an overview of the epidemiology, clinical characteristics, diagnostic process, and management of rheumatic, metabolic, dermatologic (mucocutaneous), ophthalmologic, hepatobiliary, hematologic, thromboembolic, urinary tract, pulmonary, and pancreatic extraintestinal manifestations related to IBD. Articles were identified through search of the PubMed and Embase databases, the Cochrane Library, and the web sites of the European Agency for the Evaluation of Medicinal Products (EMEA) and the US Food and Drug Administration (FDA) (cut-off date October 2009). The search terms 'Crohn's disease', 'inflammatory bowel disease', or 'ulcerative colitis' were combined with the terms 'adalimumab', 'anemia', 'arthritis', 'bronchiectasis', 'bronchitis', 'cutaneous manifestations', 'erythema nodosum', 'extraintestinal manifestations', 'hyperhomocysteinemia', 'infliximab', 'iridocyclitis', 'lung disease', 'ocular manifestations', 'osteomalacia', 'pancreatitis', 'primary sclerosing cholangitis', 'renal stones', 'sulfasalazine', 'thromboembolism', and 'treatment'. The search was performed on English-language reviews, practical guidelines, letters, and editorials. Articles were selected based on their relevance, and additional papers were retrieved from their reference lists. Since some of the diseases discussed are uncommon, valid evidence of treatment was difficult to obtain, and epidemiologic data on the rarer forms of extraintestinal manifestations are scarce. However, updates on the pathophysiology and treatment regimens are given for each of these disorders. This paper offers a current review of original research papers and randomized clinical trials, if any, within the field and makes an attempt to point out practical guidelines for the diagnosis and treatment of various extraintestinal manifestations related to IBD.

Managing the risks of IBD therapy

Successful management of the patient with inflammatory bowel disease (IBD) involves not only the induction and maintenance of remission, but also the optimization of the benefit-to-risk equation to achieve the greatest gain in quality of life. These risks range from intolerance to prescribed medications to potentially life-threatening sequelae (eg, sepsis) of immune suppression. A proper awareness of risk on the part of the physician and education of the patient can lead to early detection and institution of an appropriate management plan, including risk management and, optimally, primary prevention (eg, prophylactic vaccination). One should take the opportunity regularly to reassess the utility and efficacy of existing therapy, with the provision of ineffective therapies mandating urgent review. Overall, optimal management of the patient with IBD requires open dialogue between clinician and patient so that both are cognizant of the goals, benefits, and potential risks of therapy.

Inflammatory bowel disease in the elderly

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

Vitamin D3 and its nuclear receptor increase the expression and activity of the human proton-coupled folate transporter

Folates are essential for nucleic acid synthesis and are particularly required in rapidly proliferating tissues, such as intestinal epithelium and hemopoietic cells. Availability of dietary folates is determined by their absorption across the intestinal epithelium, mediated by the proton-coupled folate transporter (PCFT) at the apical enterocyte membranes. Whereas transport properties of PCFT are well characterized, regulation of PCFT gene expression remains less elucidated. We have studied the mechanisms that regulate PCFT promoter activity and expression in intestine-derived cells. PCFT mRNA levels are increased in Caco-2 cells treated with 1,25-dihydroxyvitamin D(3) (vitamin D(3)) in a dose-dependent fashion, and the duodenal rat Pcft mRNA expression is induced by vitamin D(3) ex vivo. The PCFT promoter region is transactivated by the vitamin D receptor (VDR) and its heterodimeric partner retinoid X receptor-alpha (RXRalpha) in the presence of vitamin D(3). In silico analyses predicted a VDR response element (VDRE) in the PCFT promoter region -1694/-1680. DNA binding assays showed direct and specific binding of the VDR:RXRalpha heterodimer to the PCFT(-1694/-1680), and chromatin immunoprecipitations verified that this interaction occurs within living cells. Mutational promoter analyses confirmed that the PCFT(-1694/-1680) motif mediates a transcriptional response to vitamin D(3). In functional support of this regulatory mechanism, treatment with vitamin D(3) significantly increased the uptake of [(3)H]folic acid into Caco-2 cells at pH 5.5. In conclusion, vitamin D(3) and VDR increase intestinal PCFT expression, resulting in enhanced cellular folate uptake. Pharmacological treatment of patients with vitamin D(3) may have the added therapeutic benefit of enhancing the intestinal absorption of folates.

Osteoporosis in adult Sri Lankan inflammatory bowel disease patients

AIM: To determine if inflammatory bowel disease (IBD) is a risk factor for osteoporosis in adult Sri Lankans.

METHODS: We identified eligible subjects from among consecutive patients diagnosed with IBD who attended our outpatient clinic. We included only patients aged between 20 and 70 years. Patients who were pregnant, had significant comorbidity, or were on calcium supplements or treatment for osteoporosis within the past 6 mo, were excluded. Healthy, age- and sex-matched controls were also recruited, in a control to patient ratio of 3:1. Both groups were screened for osteoporosis using peripheral dual energy X-ray absorptiometry scanning.

RESULTS: The study population consisted of 111 IBD patients (male:female = 43:68; mean age 42.5 years) and 333 controls (male:female = 129:204; mean age 43.8 years). The occurrence of osteoporosis among IBD patients (13.5%) was significantly higher than among controls (4.5%) (P = 0.001). The frequency of osteoporosis was not significantly different between ulcerative colitis (14.45%) and Crohn’s disease (10.7%). However, on multivariate analysis, only age (P = 0.001), menopause (P = 0.024) and use of systemic steroids (P < 0.001) were found to be associated independently with the occurrence of osteoporosis, while IBD, severity of disease, number of relapses, duration of illness or treatment other than systemic steroids were not.

CONCLUSION: IBD does not appear to be an independent risk factor for the occurrence of osteoporosis in this population. However, the use of systemic steroids was a risk factor.

High prevalence of low bone mineral density in patients with Inflammatory Bowel Disease in the setting of a peripheral Dutch hospital

BACKGROUND AND AIMS

Osteopenia and osteoporosis are frequently encountered in patients with Inflammatory Bowel Disease (IBD). Our aims were to evaluate the actual practice of screening for low bone mineral density (BMD) by dual energy X-ray absorptiometry (DEXA), to determine the prevalence of low BMD and to investigate the risk factors associated with a low BMD in the IBD population of a regional Dutch hospital.

METHODS

A retrospective chart review was performed in 474 patients (259 with ulcerative colitis, 210 with Crohn's disease and 5 with indeterminate colitis). DEXA results and potential predictive factors of low BMD were documented. Predictive factors of low BMD were assessed by logistic regression.

RESULTS

DEXA was performed in 168 IBD patients (35.4%). A low BMD (T-score<-1) was present in 64.3%. Osteoporosis (T-score<-2.5) was found in 23.8%. Low BMI, older age at the moment of diagnosis and male gender were found to be predictive factors of low BMD. For patients with osteoporosis, disease duration was an additional predictive factor. After subgroup analysis predictive factors were found to be the same in patients with Crohn's disease.

CONCLUSIONS

The prevalence of osteopenia and osteoporosis in IBD patients in a regional centre is as high as the prevalence rates reported from tertiary referral centres. A low BMI, an older age at the moment of diagnosis and male gender were predictive factors of low BMD. Prediction of osteoporosis and osteopenia using risk factors identified in this and previous studies is presently not feasible.

Vertebral deformities and inflammatory bowel disease

Loss of bone mass and an increased risk of fractures is an issue of major concern for physicians treating inflammatory bowel disease patients. Multiple causes for decreased bone mass have been identified in the past, but the role of inflammation may be of pivotal importance. We here discuss the latest insights into the pathogenesis of inflammatory bowel disease-related bone loss and the implications for treatment.

Basic and clinical aspects of osteoporosis in inflammatory bowel disease

Low bone mineral density and the increased risk of fracture in gastrointestinal diseases have a multifactorial pathogenesis. Inflammatory bowel disease (IBD) has been associated with an increased risk of osteoporosis and osteopenia and epidemiologic studies have reported an increased prevalence of low bone mass in patients with IBD. Certainly, genetics play an important role, along with other factors such as systemic inflammation, malnutrition, hypogonadism, glucocorticoid therapy in IBD and other lifestyle factors. At a molecular level the proinflammatory cytokines that contribute to the intestinal immune response in IBD are known to enhance bone resorption. There are genes influencing osteoblast function and it is likely that LRP5 may be involved in the skeletal development. Also the identification of vitamin D receptors (VDRs) and some of its polymorphisms have led to consider the possible relationships between them and some autoimmune diseases and may be involved in the pathogenesis through the exertion of its immunomodulatory effects during inflammation. Trying to explain the physiopathology we have found that there is increasing evidence for the integration between systemic inflammation and bone loss likely mediated via receptor for activated nuclear factor kappa-B (RANK), RANK-ligand, and osteoprotegerin, proteins that can affect both osteoclastogenesis and T-cell activation. Although glucocorticoids can reduce mucosal and systemic inflammation, they have intrinsic qualities that negatively impact on bone mass. It is still controversial if all IBD patients should be screened, especially in patients with preexisting risk factors for bone disease. Available methods to measure BMD include single energy x-ray absorptiometry, DXA, quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. DXA is the establish method to determine BMD, and routinely is measured in the hip and the lumbar spine. There are several treatments options that have proven their effectiveness, while new emergent therapies such as calcitonin and teriparatide among others remain to be assessed.

Optimizing drug therapy in inflammatory bowel disease

This article reviews current data to optimize the use of both older and newer drugs in inflammatory bowel disease. For patients with severe ulcerative colitis (UC), steroid dosing has been clarified, and a mega-analysis of steroid outcomes and toxicities has been reported. In regard to mesalamine, recent information has suggested benefit of a higher dose of pH-dependent release mesalamine for patients with moderate UC. Also, a once-daily formulation with Multi-Matrix System (MMX) technology (Shire Pharmaceuticals, Wayne, PA), has been approved. In regard to cyclosporine, two centers have reported an increased rate of colectomy over a long-duration follow-up of a cyclosporin A course given for UC. Additional information regarding thiopurines has been published, including the use of metabolite testing and duration of therapy for these drugs. Lastly, additional information regarding the optimal method for using anti-tumor necrosis factor therapy continues to accumulate.