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Guidelines for osteoporosis in inflammatory bowel disease and coeliac disease

• British Society of Gastroenterology •

General measures

  • General advice for all patients:
    • encourage frequent weight bearing exercise (including walking, using stairs, gardening and housework)
    • ensure nutritious diet
    • ensure adequate dietary calcium; add calcium tablets if necessary to ensure daily intake of 1000 mg (1200 mg for postmenopausal women and men>55)
    • seek (check calcium, ALP and then consider PTH) and treat vitamin D deficiency
    • no smoking
    • avoid alcohol excess
  • Advise coeliac disease (CD) patients to adhere to strict gluten-free diet
  • Treat inflammatory bowel disease (IBD) energetically to achieve/maintain remission

Steroid avoidance in IBD

  • Steroid avoidance:
  • early use of azathioprine/mercaptopurine
  • use steroids sparingly; consider budesonide instead of prednisolone for small bowel and caecal Crohn’s
  • consider elemental or polymeric diet before steroids in Crohn’s disease
  • consider biologic therapy or surgery if steroid-free remission not achieved

Bone-protective measures during steroid use in IBD

  • For those on steroids:
    • all >65: consider bisphosphonate at commencement of steroids
    • <65 at high risk and requiring steroids >3 months: DEXA and consider bisphosphonate if T-score<-1.5
    • – give vitamin D and calcium or while on steroids

Guidelines for osteoporosis in inflammatory bowel disease and coeliac disease continued

Detection

  • DEXA for those at higher risk of osteoporosis e.g. 2 or more of (also see below):
    • continuing active disease
    • weight loss >10%
    • BMI < 20
    • age >70

Risk factors for fracture related to low BMD

  • High risk
    • non-modifiable:
      • older age (>70 years)
      • prior osteoporotic fracture
    • modifiable:
      • low body weight (BMI <20–25 kg/m2 or weight <40 kg)
      • weight loss (greater than 10%)
      • physical inactivity
      • use of corticosteroids
      • use of anticonvulsants
  • Moderate risk
    • non-modifiable:
      • female
      • untreated early menopause (<45)
      • late menarche (>15)
      • short fertile period (<30 years)
      • family history of osteoporotic fracture
    • modifiable:
      • smoking
      • low calcium intake

Risk factors for fracture at least partly independent of low BMD

  • Non-modifiable:
    • older age
    • prior osteoporotic fracture
    • family history of hip fracture
    • poor visual acuity (modifiable in some cases)
    • neuromuscular disorders (modifiable in some cases)
  • Modifiable:
    • low body weight
    • use of corticosteroids
    • cigarette smoking
    • alcohol excess

Guidelines for osteoporosis in inflammatory bowel disease and coeliac disease continued

Treatment

  • Treatment of osteoporosis if low T-score on DEXA and risk factors, or if prior fragility fracture:
    • oral bisphosphonate long term, e.g. weekly risedronate or alendronic acid
    • intolerance of oral bisphosphonate: consider 3-monthly iv ibandronic acid or an alternative class of drug (see below)
    • intolerance or failure of bisphosphonate in postmenopausal women or men aged >55 consider:
      • raloxifene (for postmenopausal women long term)
      • teriparatide (by daily injection for 18 months)
      • calcitonin by intranasal spray
  • Men with low BMD: check blood testosterone and replace if low:
    • normal testosterone level in men with CD does not exclude hypogonadism because there appears to be androgen resistance, especially before treatment with a gluten-free die

 

full guidelines available from…
British Society of Gastroenterology, 3 St. Andrew's Place, Regent's Park, London NW1 4LB (Tel – 020 7935 2815

British Society of Gastroenterology. Guidelines for osteoporosis in inflammatory bowel disease and coeliac disease. June 2007

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eGuidelines.co.uk (22 May 2012)
© 2012 MGP Ltd
First included: Jun 2000. Updated: Feb 2008.
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