Transcript Osteoporosis in IBD

Osteoporosis
in IBD
General Risk Factors
for Osteoporosis

Advancing age

Smoking

Female gender

Physical inactivity

Family history

Low calcium intake

Alcohol use


White/Asian race
Small and thin body
habitus
Valentine JF, Sninsky CA. Am J Gastroenterol. 1999;94:878-883. Christchilles EA, et al. Arch Intern Med.
1991;151:2026-2032.
Risk of Osteoporosis in IBD

Low bone mass in 31% to 59% of IBD patients1-3

IBD-related risk factors4
– Onset of IBD before reaching age of peak bone mass
– Inflammatory cytokines
– Calcium malabsorption
– Vitamin D deficiency (CD patients)
– Drugs (corticosteroids, methotrexate, cyclosporine)
1Compston
JE. Aliment Pharmacol Ther. 1995;9:237-250. 2Roux C, et al. Osteoporos Int. 1995;5:185-190.
H, et al. Scand J Gastroenterol. 1997;32:1247-1255. 4Valentine JF, Sninsky CA. Am J Gastroenterol.
1999;94:878-883.
3Andreassen
Prevention and Treatment of
Osteoporosis in IBD

Prevention
– Baseline and follow-up measurements of bone density
(DEXA)
– Lifestyle and nutritional measures (eg, weight-bearing
exercise, smoking cessation, calcium supplementation)
– Possible HRT for high-risk postmenopausal women

Treatment
– Calcitonin
– Bisphosphonates
– PTH
– IV therapies
Valentine JF, Sninsky CA. Am J Gastroenterol. 1999;94:878-883.
Corticosteroid-Induced
Bone Loss

Bone loss occurs early (weeks to months after
initiation of therapy)

Cumulative dose, dosage, and duration of
corticosteroids may play a role

Calcium and small doses of vitamin D may
confer limited prophylactic benefit
Valentine JF, Sninsky CA. Am J Gastroenterol. 1999;94:878-883. Van Staa TP, et al. J Bone Mineral Res.
2000;15:993-1000.
Corticosteroid-Induced Loss
of Bone Mass

Enhanced bone resorption
– Reduced intestinal calcium absorption and calcitonin
synthesis
– Increased renal calcium excretion, osteoclastic activity,
and parathyroid hormone secretion
– Enhanced binding of macrophages to bone

Reduced bone formation
– Reduced synthesis of osteoblasts and proliferation of
osteoblasts
– Impaired gonadal hormone production
– Prednisone associated with increased rate of bone loss
– Conflicting data regarding budesonide
Reducing the Risk of
Osteoporosis
History and physical lab (25-hydroxy vitamin D, albumin, calcium, PTH)
Bone density (DEXA)
Minimize corticosteroids
Normal T Score
Monitor regularly
Low BMD:
T Score <–1 SD
Osteoporosis:
T Score <–2.5 SD
Hormone
(if appropriate)
Hormone
(if appropriate)
Raloxifene
(if appropriate)
Raloxifene
(if appropriate)
Calcium
Calcium
Vitamin D
Vitamin D
General guidelines
Bisphosphonates
Repeat DEXA
General guidelines
Repeat DEXA
Bisphosphonates in the Prevention
and Treatment of Osteoporosis
Lumbar Spine BMD
12 month diff. = 3.8%
12 month diff. = 2.7%
% Change from Baseline
2
4
*†
1
†
†
†P<.05
0
control
-1
0
3
*
†
*†
Placebo
*
-3
vs
3
2
*
-2
-4
*P<.05 vs
baseline
6
*
9
12
Ris
5.0 mg
*
1
0
0
6
Months
Months
Prevention Study
Treatment Study
Cohen S, Levy RM, Keller M, Boling E, et al. Risedronate therapy
prevents corticosteroid-induced bone loss: a twelve-month,
multicenter, randomized, double-blind, placebo-controlled,
parallel-group study. Arthritis Rheum. 1999;42:2309-2318.
Copyright© American College of Rheumatology. Reproduced
with permission of John Wiley & Sons, Inc.
12
Reproduced from J Bone Miner Res. 2000:15;1006-1013 with
permission of the American Society for Bone and Mineral
Research.
Infliximab in Patients
With CD and Osteoporosis

Prospective, 4-week trial with patients taking
corticosteroids

Significant decrease in CDAI with infliximab
(P=.0001)

Increase in surrogate markers for bone turnover

Conclusion: increased bone synthesis with
no increase in bone resorption
CDAI = Crohn’s disease activity index.
Abreu MT, et al. Am J Gastroenterol. 2002;97:S269. Abstract 819.
Summary:
Osteoporosis and IBD

Bone density is unusually low in patients with
active IBD who are taking steroids

IBD causes other risk factors, eg, poor calcium
absorption and disease-related inflammatory
processes, that increase risk of bone loss

Monitoring BMD is important

Selection of treatment should be considered