Bone Health Guidelines for Patients With Chronic Pancreatitis

Abstract

We noted with interest the recent article published in Gastroenterology by Prof Forsmark on the clinical management of chronic pancreatitis.1Forsmark C.E. Gastroenterology. 2013; 144: 1282-1291Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar The author recommended the inclusion of bone health as a key aspect for medical therapy in this group—a vitally important and, up to now, neglected area of chronic pancreatitis management. Osteopenia or osteoporosis are complications of chronic pancreatitis for two-thirds2Duggan S.N. et al.Clin Gastroenterol Hepatol. 2013 Jul 12; ([Epub ahead of print])Google Scholar of patients but may, in fact, be present in more than 3 in 4 patients in some populations.3Haaber A.B. et al.Int J Pancreatol. Feb 2000; 27: 21-27Crossref PubMed Google Scholar, 4Duggan S.N. et al.Pancreas. 2012; 41: 1119-1124Crossref PubMed Scopus (54) Google Scholar Prof Forsmark stated that osteopathy is seen in those with exocrine insufficiency, but in reality, it appears to be present even in those without significant exocrine impairment.2Duggan S.N. et al.Clin Gastroenterol Hepatol. 2013 Jul 12; ([Epub ahead of print])Google Scholar While the pathogenesis of bone demineralization in this group has not been characterized, contributory factors include smoking, poor diet, and low sunlight exposure. The American Gastroenterological Association (AGA) recommended that patients with gastrointestinal conditions (inflammatory bowel disease [IBD], celiac disease and post-gastrectomy) should undergo bone density assessment by dual-energy X-ray absorptiometry (DXA) if they have at least one additional osteoporosis risk factor (previous low-trauma fracture, post-menopausal women, hypogonadism, or patients on corticosteroid therapy in IBD).5Tignor A.S. Am J Gastroenterol. 2010; 105: 2680-2686Crossref PubMed Scopus (79) Google Scholar Chronic pancreatitis was not considered by the AGA in its bone health guidelines, likely due to a lack of studies at that time. While baseline DXA for all patients with chronic pancreatitis would be the most preferable method of screening for osteoporosis in this group, the AGA stated that to recommend bone density assessment for all patients would result in numerous unnecessary tests. At the very least for patients with chronic pancreatitis, it seems prudent to recommend a DXA for post-menopausal women, those with a previous low-trauma fracture, and men over 50 years, as well as those with malabsorption. For bone health, all patients with chronic pancreatitis should be counseled on basic preventative measures, including adequate dietary calcium and vitamin D, weight-bearing exercise, and smoking/alcohol avoidance. In line with the AGA recommendations for gastrointestinal diseases, those with osteopenia should undergo repeat DXA after 2 years, while those with osteoporosis (and those with vertebral compression fractures regardless of DXA) should receive appropriate medication and screening for other causes or be referred to a bone specialist for further evaluation.6American Gastroenterological Association Medical Position Statement: Guidelines on Osteoporosis in Gastrointestinal Diseases.Gastroenterology. 2003; 124: 791-794Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar These measures are critical for reducing the burden of osteoporosis and increased fracture risk5Tignor A.S. Am J Gastroenterol. 2010; 105: 2680-2686Crossref PubMed Scopus (79) Google Scholar for this nutritionally vulnerable patient group. Management of Chronic PancreatitisGastroenterologyVol. 144Issue 6PreviewAdvances in our understanding of chronic pancreatitis have improved our care of patients with this disease. Although our therapies are imperfect and many patients remain symptomatic, appropriate medical care improves the quality of life in these patients. Proper management requires an accurate diagnosis, recognition of the modifiable causes of disease, assessment of symptoms and complications, treatment of these symptoms and complications utilizing a multidisciplinary team, and ongoing monitoring for the effect of therapy and the occurrence of complications. Full-Text PDF ReplyGastroenterologyVol. 145Issue 4PreviewI thank Drs Duggan and Conlon for their comments on my recent review on the clinical management of chronic pancreatitis.1 They correctly point out that osteopenia and osteoporosis may be present in those with chronic pancreatitis but without obvious exocrine insufficiency, and I would alert those interested in this topic to a recent review from these authors.2 The consequences of osteoporosis and fracture risk in these patients are well documented.3 Certainly the coexistence of exocrine insufficiency and osteopathy is well established,4 and the difficulty in documenting the presence of exocrine insufficiency due to limitations in currently available diagnostic testing reinforce the points made by Drs Duggan and Conlon. Full-Text PDF