Review
Osteoporosis in Inflammatory Bowel Disease

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Abstract

Osteoporosis commonly afflicts patients with inflammatory bowel disease, and many factors link the 2 states together. A literature review was conducted about the pathophysiology of osteoporosis in relation to inflammatory bowel disease. Screening guidelines for osteoporosis in general as well as those directed at patients with inflammatory bowel disease are reviewed, as are currently available treatment options. The purpose of this article is to increase physician awareness about osteopenia and osteoporosis occurring in patients with inflammatory bowel disease and to provide basic, clinically relevant information about the pathophysiology and guidelines to help them treat these patients in a cost-effective manner.

Section snippets

Pathophysiology of Osteoporosis in Inflammatory Bowel Disease

Bone is a living tissue that undergoes constant remodeling by bone-forming cells (osteoblasts) and bone-resorbing cells (osteoclasts). Imbalances in bone formation and resorption lead to osteoporosis. Several gastrointestinal disorders have been associated with osteoporosis and osteopenia, including inflammatory bowel disease, celiac disease, and chronic liver disease.5, 6 The etiology of osteoporosis in inflammatory bowel disease is multifactorial, with risk factors including age,

Role of Corticosteroids

Because glucocorticoids are a treatment mainstay for chronic inflammatory diseases, it is important to recognize the effects they have on bone remodeling. They have been shown to impair osteoblast function, induce osteoblast apoptosis, reduce intestinal calcium absorption, and increase renal excretion of calcium.5, 7 Patients on glucocorticoids are at increased risk for fracture, with the greatest bone loss occurring in the initial months of treatment.8 Interestingly, studies show a decrease in

Role of Inflammation

There is a developing wealth of information about the role of inflammation in Crohn's disease and ulcerative colitis and the development of osteoporosis. In inflammatory bowel disease, the immune response, mediated by T lymphocytes and other inflammatory cells like macrophages, leads to production of various proinflammatory cytokines such as interleukin (IL)-2 and tumor necrosis factor (TNF). Within mononuclear cells, the key nuclear transcription factor is nuclear factor-kappa B (NFκB), which

Genetic Factors

The recent discoveries of signal transduction pathways and transcription factors critical for osteoblast differentiation and function have opened up new approaches to the understanding of the pathogenesis of osteoporosis.22 Identification of the critical role for the Wnt (wingless genes) signaling pathway in regulating osteoblast function is of particular interest, because it has been shown to play an important role in determining bone mass and strength.23 The precise mechanisms whereby Wnt

Nutritional Factors

Inflammatory bowel disease-related nutritional deficiencies have been implicated as other pathogenic mechanisms resulting in low bone mineral density. Calcium is required for normal growth and development of the skeleton. Adequate calcium intake is critical to achieving optimal peak bone mass and modifies the rate of bone loss associated with aging. Calcium deficiency (as a result of either low intake or poor intestinal absorption) has been reported in Crohn's disease.27 Vitamin D deficiency

Screening Guidelines

The World Health Organization (WHO) defines osteoporosis as bone mineral density at the hip or spine < 2.5 standard deviations below the mean for young healthy sex- and race-matched adults. Although bone mineral density assessment is the most common means of diagnosing osteoporosis, the WHO has developed a web-based interactive tool, FRAX™ (Fracture Risk Assessment Model), that includes 10 risk factors.33 This tool helps physicians calculate the 10-year probability of having major osteoporotic

Nonpharmacologic Therapies

Several nonpharmacologic therapies are recommended for all patients at risk for developing osteoporosis, including those suffering from inflammatory bowel disease (Table 2).6, 35, 36 These include regular weight-bearing exercise (resulting in improved bone mineral density and decreased risk of fall from increased agility, strength, and balance), avoidance of tobacco use and limiting alcohol intake (both risk factors on the WHO's Fracture Risk Assessment Tool),33 and fall prevention. It is

Conclusion

Osteoporosis imparts a significant burden on today's health care system, accounting for high costs, increased hospitalizations, disability, and time lost from work. Considerable information is known about osteoporosis and inflammatory bowel disease, but further work is needed. As more is understood about the pathophysiology linking these diseases, more treatment modalities will become available. For physicians, it is important to recognize the risk factors that are associated with inflammatory

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  • Cited by (0)

    Funding: Dr. Humphrey received funding from US Department of Veterans Affairs.

    Conflict of Interest: None.

    Authorship: All authors contributed to writing this manuscript.

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