Osteoporosis, Fracture Risk Higher in Patients With IBD

Marcia Frellick

February 19, 2020

MAUI, Hawaii — Osteoporosis affects about 15% of people with inflammatory bowel disease (IBD), but the disease pattern is different than in the general population, said gastroenterologist Millie Long, MD, from the Department of Medicine at the University of North Carolina in Chapel Hill.

In the general population, those who develop osteoporosis are typically women who are thin and postmenopausal, and family history, smoking status, and alcohol use usually play a role, Long said here at the Gastroenterology Updates IBD Liver Disease Conference 2020.

But in the population with IBD, the risk for osteoporosis is similar in women and men, age plays a large role, and corticosteroid use seems to be a driving factor in the development of the disease, she explained.

A previous study that looked at fractures in patients with IBD showed that the risk "is 40% greater than in the general population," Long reported. In patients younger than 40 years, the risk for fracture was 37% higher than in the general population, and this rate increased with age.

Table. Combined Risk for Hip, Spine, Wrist, Forearm, and Rib Fractures in IBD Patients Compared With the General Population
Age Group Incident Risk Ratio 95% Confidence Interval
0 to 39 1.37 1.10–1.69
40 to 59 1.44 1.17–1.76
60 and older 1.41 1.27–1.56
Source: Ann Intern Med. 2000;133:795-799

Preventing Fractures

Fractures to the hip and spine are linked to significant morbidity, including hospitalization, major surgery, and even death, Long noted. But they are one of the preventable downstream effects of IBD, and patients need to understand that there's something they can do about their elevated risk.

Patients should be educated on the importance of weight-bearing exercise and quitting smoking, she said.

"We need to think of preventive measures for anyone on more than 5 mg of prednisone a day for a time period of about 3 months," she added. "Unfortunately, most of our patients meet this criterion."

Patients with IBD should undergo dual-energy x-ray absorptiometry (DXA) to calculate bone density and establish the need for calcium and vitamin D supplementation.

"One of the things I'm starting to do in my practice is check vitamin D levels annually on my patients. I do this in the springtime and try to optimize their levels," Long said.

Higher Risk for Herpes Zoster

The risk for infection is also elevated in patients with IBD, including the risk for herpes zoster, which is already high, affecting one in three people in the general population.

In fact, the risk for herpes zoster in patients with IBD in their 20s is similar to the risk for people in their 50s in the general population. This is "something we need to be addressing in all of our patients," said Long.

Physicians should emphasize the need for zoster vaccination in patients at least 50 years of age, and potentially younger patients on certain therapies, she added.

But because the Shingrix shingles vaccine (GlaxoSmithKline) is so much more powerful than the previous live vaccine, some have wondered whether it could stimulate an immune response, causing the IBD to flare after vaccination, she said.

However, a recent study of IBD patients followed for 207 days after shingles vaccination showed that only one of the 67 study participants (1.5%) experienced a flare. But fever is fairly common after the shot.

"I counsel my patients that they may feel pretty wiped out for 24 hours; they may have myalgias," Long reported. "If you have someone who has to travel for work, you want them to time this vaccination so they can have a day of rest afterward. It's the real deal."

Screening for TB

Screening to rule out latent tuberculosis (TB) is also important in IBD.

"We should be looking at whether they've had close contact with active TB or people from endemic areas," said Long. "The reason we really care about this is that the risk of serious infection is doubled with anti-TNF therapy."

The treatment of latent TB prior to the initiation of an anti-TNF "reduces the incidence of active TB by over 80%. This is why it's imperative to screen prior to initiation, and then periodically based on risk factors," she explained.

"It's profound how much maintenance is required for patients with IBD," said Christopher Stanke, MD, from the Oregon Medical Group in Eugene.

He said he is particularly struck by the collective risks for younger patients with IBD.

"Young people look to us as their only doctor. They don't even see their primary care physicians very often. We have to take over a lot of this stuff," he told Medscape Medical News.

And osteoporosis doesn't often get the attention it needs in gastroenterologists' offices, he acknowledged.

"I often check it on people as they get close to 50 or 60," said Stanke, who added that Long's presentation is a good reminder that younger patients, especially those who have been on steroids for a while, need more attention.

Gastroenterology Updates IBD Liver Disease (GUILD) Conference 2020. Presented February 18, 2020.

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