Osteoporosis In Inflammatory Bowel Disease Patients Research Articles

P065 A One-Time Education for Gastroenterologists Regarding Osteoporosis Screening for IBD Patients Improves Provider Knowledge But Not Screening Rates.

Inflammatory Bowel Disease (IBD) is a chronic gastrointestinal inflammatory condition and has been increasing in prevalence in the United States, with a 30-40% increase over the past few decades. Osteoporosis can be seen in up to 40% of IBD patients. Screening for osteoporosis in IBD patients involves the use of DEXA scans and is recommended by the IBD Cornerstone Committee for select patients, including steroid use > 3 months consecutively or a total of 1 year in the past 2 years, family history of osteoporosis, malnutrition, amenorrheic or post-menopausal. Our quality improvement study looked to improve osteoporosis screening among gastroenterologists. We conducted a retrospective chart review on all IBD patients within the St. Luke's Network and extrapolated data on age (>50 in male and >65 in female), sex, chronic glucocorticoid use (3 month consecutively or cumulative), osteoporosis/osteopenia diagnosis, vitamin D (vit-D) levels, and DEXA scan between 2019 to 2021. We gave a 5-minute presentation on current DEXA screen recommendations for patients with IBD on 5/27/2021 to all the network's gastroenterologists, which totaled 12. We performed a pre and post education survey consisting of 5 questions on provider knowledge and comfortability with osteoporosis screening. We assessed provider knowledge, as well as rates of osteoporosis screening. All statistical analyses were conducted in IBM SPSS for Windows Version 26. Chi Square tests were used to compare two groups in categorical variables while Mann-Whitney tests were done to compare continuous variables like age and vit-D levels. There were a total of 5442 patients; 3927 patients before the educational intervention on 5/27/2021 and 1515 patients after the intervention. Both pre and post intervention groups were balanced in terms of age, gender, smoking status, and alcohol risk. Percent of DEXA scans were similar between both groups (13.0% vs 12.3%, p=0.5). DEXA screening rates among patients with chronic steroid use pre-intervention vs post-intervention was 44.45 vs 42.4% respectively. Vit-D levels compared between both groups was not statistically significant (30.5 vs 31.8, p=0.1). Surveys conducted before and after the intervention showed an overall increase in percentage of agreement responses about knowledge and confidence in DEXA screening (88.5% vs 97.5%). DEXA scanning can help detect premature decrease in bone mineral density and provide physicians with the opportunity to prevent further morbidity. Our study showed no difference in DEXA screening rates before and after intervention. However, there was an increase in provider knowledge based on post-intervention surveys. A similar study showed that it took three interventions, including educational presentation, flyers, and on screen EMR reminders for there to be a sustainable improvement in the rate of DEXA screening. Our project may have required additional interventions to produce an effect and thus reinforces the need for further efforts to improve osteoporosis screening in IBD patients.

Associations of Lifestyle Factors with Osteopenia and Osteoporosis in Polish Patients with Inflammatory Bowel Disease.

Reduced physical activity (PA), smoking, and coffee and alcohol drinking constitute risk factors of osteoporosis in patients with inflammatory bowel disease (IBD). The aim of the study was to measure the bone mineral density (BMD) and frequency of osteopenia and osteoporosis in patients with IBD and their correlation with PA, smoking, coffee, and alcohol. The study group consisted of 208 patients with IBD-103 with Crohn’s disease (CD), 105 suffering from ulcerative colitis (UC). Densitometric measurements were performed using the DXA. All patients completed a questionnaire concerning PA, smoking, and coffee and alcohol consumption. The prevalence of osteopenia and osteoporosis (L2–L4) in the IBD group was 48.1%; in the CD group, it amounted to 48.6%, and in the UC group, the prevalence was equal to 33.3%. Patients with CD who were diagnosed with osteopenia and osteoporosis demonstrated reduced PA compared to patients with a normal BMD who exercised regularly (p = 0.0335). A similar observation was made in the group of women with IBD. Women with a normal BMD exercised significantly more often than women suffering from osteopenia and osteoporosis (p = 0.0146). However, no differences in BMD were observed with regard to coffee use, alcohol consumption, or smoking. Thus, since the incidence of osteoporosis in IBD patients is high, it may be dependent on PA.

Efficacy and safety of bisphosphonates in management of low bone density in inflammatory bowel disease: A meta-analysis.

This study aims to determine whether bisphosphonates are safe, as well as effective against bone mineral loss in inflammatory bowel disease (IBD). A computerized search of electronic databases from 1966 to 2016 was performed. Randomized controlled trials (RCTs) were included in this review to evaluate the role of bisphosphonates in the management of osteoporosis in IBD patients. A revised 7-point Jadad scale was used to evaluate the quality of each study. Overall, 13 RCTs and 923 patients met the inclusion criteria of this meta-analysis. The result showed that bisphosphonates decreased bone mass density (BMD) loss at the lumbar spine (P = 0.0002), reduced the risk of new fractures (P = 0.01), and retained the similar adverse events (P = 0.86). Bisphosphonates may provide protection and safety against bone mineral loss in IBD patients.

Bone Metabolism and the c.-223C>T Polymorphism in the 5'UTR Region of the Osteoprotegerin Gene in Patients with Inflammatory Bowel Disease.

Osteoporosis is more frequent in inflammatory bowel disease (IBD) patients. A reduction in bone mineral mass in these individuals is caused not only by inflammatory processes in the bowel, because osteoporosis occurs already in very young IBD patients and in newly diagnosed individuals who have not yet undergone any pharmacological treatment. One of individual determinants of the bone turnover parameters is osteoprotegerin (OPG) encoded by the TNFRSF11B gene. The c.-223C > T polymorphism in this gene has been extensively studied in post-menopausal osteoporosis patients. However, no such studies exist for osteoporosis related to IBD. The aim of our study was to determine whether the c.-223C > T (rs2073617) polymorphism in the 5′UTR region of the gene encoding osteoprotegerin is a functional polymorphism which may change the gene expression and resulting OPG levels, and so be associated with osteopenia and osteoporosis, and impaired bone metabolism in Crohn’s disease and ulcerative colitis patients. Our study included 198 IBD patients and 41 healthy controls. Lumbar spine and femoral neck bone mineral density, T-score, Z-score as well as OPG, RANKL, vitamin D, calcium and interleukin 4 and 10 concentrations were determined for all study subjects. Genotyping of the TNFRSF11B polymorphic site was performed by restriction fragment length polymorphism technique. Statistical analyses were conducted using Statistica software. Odds ratios, 95 % confidence intervals, and P values were calculated using the HWE calculator. Our results did not allow determining an unequivocal association between the polymorphic variants of the TNFRSF11B 5′UTR region and a susceptibility to osteoporosis in IBD patients. We have shown, however, that the c.-223T allele was twice as more frequent in Crohn’s disease (CD) patients than among controls (OR = 1.99, P value = 0.009). Interestingly, average osteoprotegerin levels in CD patients did not significantly differ from those in controls, whereas in ulcerative colitis patients, OPG levels were significantly lower. We have concluded that low OPG levels may be associated with osteoporosis in ulcerative colitis, but it is not correlated with the c.-223C > T polymorphism in the TNFRSF11B gene. In CD patients, in turn, we observed increased RANKL levels. Our observations confirm different pathogeneses of Crohn’s disease and ulcerative colitis as well as different molecular backgrounds of osteoporosis associated with these two diseases.

Risk factors for osteoporosis in inflammatory bowel disease patients.

Inflammatory bowel disease (IBD) patients exhibit higher risk for bone loss than the general population. The chronic inflammation causes a reduction in bone mineral density (BMD), which leads to osteopenia and osteoporosis. This article reviewed each risk factor for osteoporosis in IBD patients. Inflammation is one of the factors that contribute to osteoporosis in IBD patients, and the main system that is involved in bone loss is likely RANK/RANKL/osteoprotegerin. Smoking is a risk factor for bone loss and fractures, and many mechanisms have been proposed to explain this loss. Body composition also interferes in bone metabolism and increasing muscle mass may positively affect BMD. IBD patients frequently use corticosteroids, which stimulates osteoclastogenesis. IBD patients are also associated with vitamin D deficiency, which contributes to bone loss. However, infliximab therapy is associated with improvements in bone metabolism, but it is not clear whether the effects are because of inflammation improvement or infliximab use. Ulcerative colitis patients with proctocolectomy and ileal pouches and Crohn's disease patients with ostomy are also at risk for bone loss, and these patients should be closely monitored.

High prevalence of hypovitaminosis D and osteoporosis in inflammatory bowel disease patients

Objectives Inflammatory bowel disease (IBD) is a group of immune-mediated diseases affecting the gastrointestinal tract. There is a high prevalence of vitamin D deficiency and osteoporosis in patients of IBD. It is not known whether vitamin D deficiency is a predisposing factor or a consequence of IBD. The aim of this study was to evaluate the association between serum vitamin D status and osteoporosis in IBD patients. Materials and methods A total of 34 patients of IBD, 22 ulcerative colitis (UC) and 12 Crohn's disease (CD), were recruited in a retrospective cross-sectional study. Serum 25-hydroxy vitamin D was assessed by the chemiluminescent assay. Bone mineral density was assessed using dual-energy X-ray absorptiometry scan of the lumbar spine and left hip joint. Results There is a high prevalence of hypovitaminosis D (deficiency and insufficiency) in patients of IBD (94.2%). There are no significant differences in vitamin D deficiency with respect to IBD subtype (UC or CD), patient sex, or disease activity. Bone mineral density is reduced in IBD patients irrespective of the disease subtype (UC or CD) or steroid therapy. Conclusion Vitamin D deficiency is prevalent in IBD patients. Vitamin D deficiency is not associated with patient sex, disease subtype, or activity. Osteoporosis is prevalent in IBD patients irrespective of steroid therapy or IBD subtype.

PTU-067 Dual-Energy X-Ray Absorptiometry Utility in Inflammatory Bowel Disease: Bsg, Frax, Nogg or Nice?

IntroductionPatients with inflammatory bowel disease (IBD) have a 40% higher risk of osteoporotic fractures than the general population. In 2007 the British Society of Gastroenterology (BSG) produced Guidelines for Osteoporosis...

The study of bone demineralization and its risk factors in an Afro-Caribbean subset of patients with inflammatory bowel disease

Bone demineralization has been increasingly recognized as a disease process concurrent with inflammatory bowel disease (IBD). Racial variation in osteoporosis in IBD patients has been poorly described. We sought to identify the risk factors for demineralization in Afro-Caribbeans (AC) with IBD. A retrospective chart review was performed from a 10-year prospectively collected database of IBD patients seen at an urban medical center. Data on dual-energy X-ray absorptiometry (DXA) scanning, use of steroids, bisphosphonates, calcium, and vitamin D, as well as blood chemistries were collected. One hundred and fifteen charts of AC IBD patients were reviewed, of which 24 patients had undergone DXA scanning. Fourteen patients with a T-score of less than -1 were compared with 10 patients with DXA scores of more than -1. Two patients with T-scores of less than -1 had fractures, whereas none were observed in the comparison group (P=0.5). The mean BMI for those with T-scores of less than -1 was 23.9 kg/m compared with 31.5 kg/m in those with T-scores of more than -1 (P=0.0034). Screening for bone demineralization in ethnic populations with IBD is lacking as only 21% of AC IBD patients seen in our institution had undergone a DXA scan. Of those who were scanned, more than half of the patients had T-scores suggestive of bone demineralization. Although those who were obese did not have demineralization, our sample sizes were small and the results from this study should prompt further investigation to determine the prevalence and significance of bone demineralization in minority populations with IBD.

Role of Ghrelin and Insulin-like Growth Factor Binding Protein-3 in the Development of Osteoporosis in Inflammatory Bowel Disease

A high prevalence of bone loss is observed in patients with inflammatory bowel disease (IBD). Leptin, ghrelin, insulin-like growth factor (IGF)-1, and IGF binding protein (IGFBP)-3 have been suggested to interfere in the bone metabolism. The aim of this study was to investigate the role of these peptides in the development of osteoporosis in IBD. One hundred and eighteen consecutive IBD patients were included. All patients underwent bone densitometry by dual energy x-ray absorptiometry at the femoral neck and lumbar spine levels. Serum samples were collected from all patients and analyzed for concentrations of the aforementioned peptides by radioimmunoassay. Forty (33.9%) patients were normal, 55 (46.6%) were osteopenic, and 23 (19.5%) were osteoporotic. Positive statistically significant correlations were found between body mass index (BMI), leptin, IGFBP-3 levels, and the bone mineral density (BMD) of the femoral neck and lumbar spine. Moreover, an inverse statistically significant correlation was found between BMD of the femoral neck and the lumbar spine, and age, duration of the disease, and ghrelin levels. Multivariate analysis revealed that the most significant factors associated with the BMD were age and BMI. A weak but statistically significant correlation was found between IGFBP-3 and femoral neck BMD (P=0.045) and between ghrelin and spine BMD (P=0.039). No correlation was observed between leptin and BMD. Low BMI is the most important independent risk factor for osteoporosis in IBD patients. There is no independent influence of leptin but ghrelin and IGFBP-3 may play a role in the bone metabolism in the IBD.

Prevalence of Bone Demineralization in AfroCaribbeans with Inflammatory Bowel Disease

Purpose: Osteoporosis/osteopenia has been increasingly recognized as a disease process concurrent with inflammatory bowel disease (IBD). Several inciting factors include malabsorption of Vitamin D and calcium, corticosteroid therapy, inflammatory cytokines, and smoking. Racial variation of osteoporosis in IBD patients has been poorly described. We sought to identify risk factors for bone demineralization in AfroCaribbean (AC) with IBD. Methods: A retrospective chart review was performed from a 10-year-old prospectively collected database of IBD patients (age >18 years) seen at a large urban university medical center. Data on dual energy X-ray absorptiometry (DXA) scanning, use of steroids, bisphosphonates, calcium, and vitamin D, as well as blood chemistries were collected and analyzed using the student's t-test and chi-square test as appropriate. Results: 115 charts of AC IBD patients [37 Crohn's disease (CD), 2 indeterminate colitis, 76 ulcerative colitis (UC)] were reviewed of which 24 patients (14 UC, 10 CD) had DXA scanning performed.10 patients had T-scores > -1, 14 patients had scores of < -1 of which 6 patients had scores <-2.5. 14 patients with a T-score of < -1 (mean age of 51 years, SD +/-20.4) were compared to ten patients with DXA scores > -1 (mean age 50.1 years, SD +/-14.9).Two patients with T-scores <-1 had fractures while none were observed in the comparison group (p=0.5). Mean body mass index (BMI) for those with T-scores <-1 was 23.9 kg/m2 compared to 31.5 kg/m2 in those with T-scores >-1 (p=0.0034). Two thirds of the patients with lower T-scores were prescribed treatment. See Table 1 for results. Conclusion: Screening for bone demineralization in ethnic populations with IBD is lacking as only 21% of AC IBD patients seen in our institution had a DXA scan. Of those who were scanned, more than half of the patients had T-scores suggestive of bone demineralization. Although elevated BMI was protective against demineralization in AC patients with IBD, these results should prompt further studies to determine the prevalence and significance of bone demineralization in minority populations with IBD.Table

Survey of gastroenterologistsʼ awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: Are the guidelines being used and what are the barriers to their use?

The American Gastroenterology Association (AGA) published guidelines to assist clinicians in the evaluation and management of osteoporosis in inflammatory bowel disease (IBD) patients. Two studies suggest that when clinicians utilized the guidelines, the majority of their IBD patients were appropriately screened and treated for metabolic bone disease. The aim was to study whether physicians who say they use the AGA Guidelines are, in fact, following the recommendations, and to assess the barriers preventing the use of the guidelines in the management of osteoporosis in their IBD patients. In all, 1000 physicians were selected from the AGA membership list and mailed a survey inquiring into awareness and implementation of the guidelines on osteoporosis in IBD patients. The barriers to implementation of the guidelines were also assessed. The sum of 21 self-reported clinical practices (absence = 0, presence = 1) was used to evaluate adherence to the guidelines. A value of 0 implied no adherence while a score of 21 meant complete adherence. Of 304 responders, 27 fellows, 8 retirees, and 11 incomplete responses were not included in the analysis; thus, 258 respondents were the subject of this analysis. Slightly less than half of the responders used the guidelines in decision-making (126, 49%) or in the management (110, 42%) of their IBD patients. Using the scoring system described above, clinicians self-reporting use of the guidelines had a significantly higher clinical practice score than those who did not use the guidelines (Wilcoxon rank sum test; P < 0.0001). Only 18% (12 of 68) of clinicians whose practice was comprised of <or=25% IBD patients used the guidelines compared to 60% (113/187) physicians who cared for more IBD patients (chi-square test; P < 0.0001). Physicians who saw more IBD patients (>25%) were also more likely (97/187 = 52%) to assess and treat osteoporosis in their IBD patients. Conversely, only 16% (11/68) of physicians who saw <or=25% IBD patients treated osteoporosis (chi-square test; P < 0.0001). The main reason physicians (n = 115) gave for not utilizing the guidelines was because they felt that IBD should be the focus of the visit (48, 42%); 34 (30%) reported that osteoporosis should be managed by another physician. Other barriers cited were lack of time (13, 11%), cost (10, 9%), and lack of knowledge (10, 9%). Most of the responding physicians do not utilize the AGA Guidelines on metabolic bone disease in IBD patients. The physicians who self-reported utilizing the guidelines were actually adhering to the recommendations. Further education regarding the impact of metabolic bone disease in IBD patients and the importance of the guidelines is needed, particularly as it addresses the barriers set forth above.

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.

Examination, prevention and treatment of osteoporosis in patients with inflammatory bowel disease: recommendations and reality.

Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. Our aim was to evaluate the current practices of examination, prevention and treatment of osteoporosis in IBD patients in a routine clinical setting. A total of 154 consecutive patients with IBD (63 female, 91 male; 36 ulcerative colitis, 115 Crohn's disease, 3 indeterminate colitis), referred to two gastroenterological units for scheduled follow-up examinations, were included. Patient charts were evaluated regarding bone densitometry already performed and any prophylactic or therapeutic interventions in cases of low bone mineral density. Bone mineral density (BMD) measurements had been performed only in 38 patients (25%). BMD was abnormally low in 27 of the examined patients (71%), 20 of whom had osteopenia and seven had osteoporosis. Among the subgroup of patients on long-term steroid therapy (77 patients), 30 had been referred to bone densitometry during the course of disease, and 21 of them were found to have low bone mineral density. Preventive measures were prescribed in 12 patients (9% of the whole study population). In the majority of the patients with low bone mineral density, calcium and vitamin D were used as treatment. Despite the high prevalence of osteopenia and osteoporosis in patients with IBD, only a minority of these patients were included in a structured program in accordance with modern guidelines for diagnosing and preventing this extraintestinal complication in a routine clinical setting.

Ultrasound Measurements of Calcaneus for Estimation of Skeletal Status in Patients with Inflammatory Bowel Disease

Background: Patients with inflammatory bowel disease (IBD) are at risk of developing metabolic bone disease. In diagnosing osteoporosis, bone mineral density (BMD) measurements play a key role. Our aims in this study were to assess the skeletal status with quantitative ultrasound (QUS) and to evaluate the ability of this method to predict BMD as measured by dual-energy X-ray absorptiometry (DXA) in IBD patients. Methods: Altogether 53 patients with Crohn disease (CD) and 57 with ulcerative colitis (UC) were studied by using a Lunar Achilles ultrasound bone densitometer. The ultrasound variables are broadband ultrasound attenuation (BUA) and speed of sound (SOS). The lumbar spine, femoral neck, and total body BMD were measured with DXA. The age- and sex-adjusted values (Z-scores) were obtained by comparison with age- and sex-matched normal values. Results: In CD patients Z-scores for both BUA and SOS were significantly less than zero, and Z-score for SOS was significantly lower than that for UC patients. Z-scores for BMD measured with DXA were significantly lower at all measurements in patients with CD. QUS and DXA measurements were significantly correlated. However, the agreement between the measurements in each individual patient was poor. Body mass index (BMI) was a major determinant for both BUA and SOS. In CD patients low QUS variables were associated with corticosteroid therapy, and both CD and UC patients with previous fractures had low SOS values. Conclusions: Our study indicates that QUS and DXA are not interchangeable methods for estimation of bone status. QUS variables are insufficient to provide accurate prediction of BMD values and should therefore not be recommended as a screening test for osteoporosis in IBD patients.