Osteoporosis (OP) is a relatively common complication of inflammatory bowel disease (IBD), with estimates of up to 42% of patients being affected.1 Patients with IBD can develop OP through several pathways, including medications (eg, corticosteroids), calcium and vitamin deficiencies (including malabsorption secondary to inflammation), chronic systemic inflammation, and overall malnutrition.1 The proinflammatory state found in IBD can be driven by increased levels of interleukin-1 and 6 along with tumor necrosis factor alpha (TNF-α), all of which stimulate bone resorption.2 Risk factors include corticosteroid therapy, hypogonadism, nutritional deficiencies, low body mass index (BMI), increasing age, female sex, and degree of inflammation.1
Reviewing a patient’s potential risk for OP should be a routine part of each visit for patients with IBD. It is important to note that certain gastrointestinal societies have slightly varying recommendations, both among each other and with general internal medicine guidelines. The 2017 American College of Gastroenterology (ACG) guidelines recommend screening patients with IBD for OP with bone mineral density (BMD) testing at the time of diagnosis and “periodically” after diagnosis.1 More specifically, some gastroenterologists have advocated for BMD assessment at initial diagnosis and then again within a year. However, these 2017 guidelines state that there is not enough evidence to support this protocol.1 Therefore, these guidelines default to those provided for the general population, although some of these vary among societies as well.
Typically, dual-energy X-ray absorptiometry (DEXA) scanning is used as the modality of choice for BMD assessment. At minimum, postmenopausal women aged 65 and older and men aged 70 years and older should be screened, regardless of IBD status.1 Certain patients with IBD who have significant exposure to corticosteroids should be considered for more frequent screening, including those patients receiving doses of >7.5 mg/day of prednisone-equivalent for longer than 3 consecutive months. In these scenarios, these patients should be screened prior to starting steroids.1
The 2017 ACG guidelines vary slightly from those published by the Crohn’s and Colitis Foundation (CCF) in 2020.3 The CCF guidelines recommend screening for OP with a DEXA scan (central and spine) in all patients with IBD who have any risk factors for OP. These risk factors include low BMI, >3 months of cumulative steroid exposure, smokers, postmenopausal women, and hypogonadism. If the initial DEXA scan is negative, then a repeat scan in 5 years should be considered, unless there are other mitigating factors (eg, increased steroid use).
Health maintenance in IBD is a topic with increasing research interest, as it can have a significant impact on a patient’s overall clinical outcomes. At the recent Digestive Disease Week 2021 annual meeting, a group led by Eltelbany et al published an abstract evaluating the impact of biologics on OP and bone fractures in patients with IBD. The authors used a national database to identify 135,630 patients with Crohn disease (CD) and 112,060 with ulcerative colitis (UC), of which 19.3% and 8.4% received biologics, respectively. Patients with CD and UC had statistically significantly higher prevalence of OP (8.3% and 7.4%) and bone fractures (8.9% and 8.7%), respectively, when compared against patients without IBD (3.7% and 9.0%; P <.001).
Patients with CD treated with biologics had lower prevalence of OP (7.3%) and bone fractures (6.8%) compared against those who did not receive biologics (12.7% and 14.6%, respectively; P <.001). In addition, patients with UC treated with biologics had lower prevalence of OP (5.9%) and bone fractures (5.5%) compared against patients who did not receive biologic therapy (11% and 14.9%, respectively; (P <.001). Further, 94% of patients with CD and 96% of patients with UC who received biologics had a history of receiving corticosteroids, although the exact amounts were not included in the abstract. This may indicate that the biologics provide a benefit outside of just steroid-sparing. The final manuscript of this abstract merits review if additional data is given comparing the different biologic classes and overall impact of cumulative steroid dosing.
Although it is a different disease state, there has been positive data regarding the impact of biologics on BMD and OP in patients with rheumatoid arthritis.5,6 Chen et al recently published data showing that patients receiving medications also used in IBD treatment, such as certain anti-TNF-α agents (adalimumab, golimumab, certolizumab) and the Janus Kinase inhibitor tofacitinib, preserved BMD over a 3 year observational period.5 A similar systematic review conducted by Zerbini et al which evaluated 28 prior studies found that anti-TNF inhibitors either preserved or improved BMD.6
There are multiple recommendations for preventive measures for OP in patients with IBD that can be reinforced during regular office visits.3 These include limiting steroid use, limiting alcohol consumption, smoking cessation, regular physical activity, and consideration of calcium and vitamin D supplementation under physician guidance. Finally, utilization of steroid sparing agents such as biologics and/or immodulators, as well as steroids with high first-pass metabolism such as budesonide, should be considered.
1. Farraye FA, Melmed GY, Lichtenstein GR, Kane SV. ACG clinical guideline: preventive care in inflammatory bowel disease. Am J Gastroenterol. 2017;112(2):241-258. doi:10.1038/ajg.2016.537
2. Lima CA, Lyra AC, Rocha R, Santana GO. Risk factors for osteoporosis in inflammatory bowel disease patients. World J Gastroint Pathophysiol. 2015;6(4):210-18. doi:10.4291/wjgp.v6.i4.210
3. Health maintenance summary. Crohn’s and Colitis Foundation. Published June 10, 2020. Accessed July 20, 2021. https://www.crohnscolitisfoundation.org/sites/default/files/2019-09/Health%20Maintenance%20Checklist%202019-3.pdf
4. Eltelbany A, Khoudari G, Mohammed A, Hamid O, Trakroo S, Regueiro MD. Impact of biologics on the prevalence of osteoporosis and bone fractures among patients with inflammatory bowel disease: a nationwide population-based study. In: Proceedings from the Digestive Disease Week Annual Meeting; May 21-23, 2021; Virtual Meeting. Abstract 612.
5. Chen JF, Hsu CY, Yu SF, et al. The impact of long-term biologics/target therapy on bone mineral density in rheumatoid arthritis: a propensity score-matched analysis. Rheumatol (Oxford). 2020;59(9):2471-2480. doi:10.1093/rheumatology/kez655
6. Zerbini CAF, Clark P, Mendez-Sanchez L, et al. Biologic therapies and bone loss in rheumatoid arthritis. Osteoporos Int. 2017;28(2):429-446. doi:10.1007/s00198-016-3769-2