Risk factors for osteoporosis in inflammatory bowel disease patients

Fatigue, sarcopenia, and frailty in older adults with inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are characterized by a multifactorial clinical picture, in which age-related physical, functional and psychological symptoms may coexist. The accurate evaluation and identification of such symptomatology acquires considerable importance in the context of older adults, since those core factors typical of IBD may also expose older patients to an increased risk for age-related negative outcomes, such as frailty and disability. The purpose of the present review was to provide an updated overview on the evaluation and management of IBD in the elderly population, with regard to fatigue, sarcopenia, and frailty. The assessment of fatigue might contribute to the identification of early symptoms of IBD, such as pain and mood disorders, which should be treated timely to offer elderly patient a better quality of life. Similarly, an accurate evaluation of sarcopenia might represent a useful Prognostic Index to identify those patients at risk of developing physical frailty. Frailty in IBD should be evaluated not only in relation to the occurrence of negative outcomes, but also should be considered itself as an outcome itself in IBD. A recommendation for future research on this topic might be the implementation of randomized trials, which include older adults and evaluate fatigue, sarcopenia, and frailty. Similarly, the development of tailored intervention programs, based on both physical and psychological outcomes, with the purpose of improving patients' adaptation to the disease, and monitoring the evolution of symptoms and the response to therapies over time, should be encouraged.

Identification of neutrophil extracellular traps and crosstalk genes linking inflammatory bowel disease and osteoporosis by integrated bioinformatics analysis and machine learning

Musculoskeletal deficits are among the most common extra-intestinal manifestations and complications of inflammatory bowel disease (IBD). This study aimed to identify crosstalk genes between IBD and osteoporosis (OP) and potential relationships between crosstalk and neutrophil extracellular traps (NETs)-related genes. Three common hub genes from different compared groups are actually the same, namely HDAC6, IL-8, and PPIF. ROC showed that the combined diagnostic value of HDAC6, IL-8, and PPIF was higher than each of the three key hub genes. Immune infiltration results showed that HDAC6 and IL-8 key genes negatively correlated with CD65 bright natural killer cells. USF1 was the common upstream TFs between HDAC6 and PPIF, and MYC was the common upstream TFs between IL-8 and PPIF in RegNetwork. Taken together, this study shows a linked mechanism between IBD and OP via NETs and crosstalk genes. These findings may show light on better diagnosis and treatment of IBD complicated with OP.

Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages

Immuno-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease are characterised by pathophysiological mechanisms wherein the immune system erroneously targets the body's own tissues. This review explores the heightened vulnerability of women with IMIDs, influenced by hormonal modulators like estrogen and progesterone. The challenges this poses are multifaceted, encompassing the impact of active disease and medical treatments throughout life stages, including family planning, fertility, and menopause. From the perspectives of rheumatologists and gastroenterologists, we review current management strategies and underscore the need for a multidisciplinary and life-cycle approach to healthcare for women with IMIDs.

In vitro osteoclastogenesis in autoimmune diseases - Strengths and pitfalls of a tool for studying pathological bone resorption and other disease characteristics

Osteoclasts play a critical role in bone pathology frequently associated with autoimmune diseases. Studying the etiopathogenesis of these diseases and their clinical manifestations can involve in vitro osteoclastogenesis, an experimental technique that utilizes osteoclast precursors that are relatively easily accessible from peripheral blood or synovial fluid. However, the increasing number of methodical options to study osteoclastogenesis in vitro poses challenges in translating findings to clinical research and practice. This review compares and critically evaluates previous research work based on in vitro differentiation of human osteoclast precursors originating from patients, which aimed to explain autoimmune pathology in rheumatic and enteropathic diseases. The discussion focuses primarily on methodical differences between the studies, including the origin of osteoclast precursors, culture conditions, and methods for identifying osteoclasts and assessing their activity. Additionally, the review examines the clinical significance of the three most commonly used in vitro approaches: induced osteoclastogenesis, spontaneous osteoclastogenesis, and cell co-culture. By analyzing and integrating the gathered information, this review proposes general connections between different studies, even in cases where their results are seemingly contradictory. The derived conclusions and future directions aim to enhance our understanding of a potential and limitations of in vitro osteoclastogenesis and provide a foundation for discussing novel methods (such as osteoclastogenesis dynamic) and standardized approaches (such as spontaneous osteoclastogenesis) for future use in autoimmune disease research.

Microbial endocrinology: the mechanisms by which the microbiota influences host sex steroids

Recent progress in microbial endocrinology has propelled this field from initially providing correlational links to defining the mechanisms by which microbes influence systemic sex hormones. Importantly, the interaction between the gut-resident bacteria and host-secreted hormones has been shown to be critical for host development as well as hormone-mediated disease progression. This review investigates how microbes affect active sex hormone levels, with a focus on gut-associated bacteria hormonal modifications and the resulting host physiological status. Specifically, we focus on the ability of the microbiota to reactivate estrogens and deactivate androgens and thereby influence systemic levels of host hormones in a clinically significant manner.

Risk Variants in or Near ZBTB40 AND NFATC1 Increase the Risk of Both IBD and Adverse Bone Health Outcomes Highlighting Common Genetic Underpinnings Across Both Diseases

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased risk of osteoporosis and bone fracture. The aims of this study were to (1) confirm the association between IBD and low bone density and (2) test for shared risk variants across diseases.

METHODS

The study cohort included patients from the Michigan Genomics Initiative. Student's t tests (continuous) and chi-square tests (categorical) were used for univariate analyses. Multivariable logistic regression was performed to test the effect of IBD on osteoporosis or osteopenia. Publicly available genome-wide association summary statistics were used to identify variants that alter the risk of IBD and bone density, and Mendelian randomization (MR) was used to identify causal effects of genetically predicted IBD on bone density.

RESULTS

There were 51 405 individuals in the Michigan Genomics Initiative cohort including 10 378 (20.2%) cases of osteoporosis or osteopenia and 1404 (2.7%) cases of IBD. Patients with osteoporosis or osteopenia were more likely to be older (64 years of age vs 56 years of age; P < .001), female (67% vs 49%; P < .001), and have a lower body mass index (29 kg/m2 vs 30 kg/m2; P < .001). IBD patients with (odds ratio, 4.60; 95% confidence interval, 3.93-5.37) and without (odds ratio, 1.77; 95% confidence interval, 1.42-2.21) steroid use had a significantly higher risk of osteoporosis or osteopenia. Twenty-one IBD variants associated with reduced bone mineral density at P ≤ .05 and 3 IBD risk variants associated with reduced bone mineral density at P ≤ 5 × 10-8. Of the 3 genome-wide significant variants, 2 increased risk of IBD (rs12568930-T: MIR4418;ZBTB40; rs7236492-C: NFATC1). MR did not reveal a causal effect of genetically predicted IBD on bone density (MR Egger, P = .30; inverse variance weighted, P = .63).

CONCLUSIONS

Patients with IBD are at increased risk for low bone density, independent of steroid use. Variants in or near ZBTB40 and NFATC1 are associated with an increased risk of IBD and low bone density.

Dietary Behaviors and Beliefs in Patients with Inflammatory Bowel Disease

INTRODUCTION

Due to a lack of clear dietary guidelines, patients with inflammatory bowel disease (IBD) self-impose dietary restrictions based on their own nutritional experiences. The aim of this study was to investigate dietary perceptions and behavior in IBD patients.

MATERIALS AND METHODS

A total of 82 patients (48 with Crohn's disease and 34 with ulcerative colitis) participated in this prospective, questionnaire-based study. Based on a literature review, the questionnaire was developed to investigate dietary beliefs, behaviors and food exclusions during IBD relapses and remission.

RESULTS

The majority of patients (85.4%) believed that diet can be a trigger factor for IBD relapses, and 32.9% believed that diet initiates the disease. The majority of patients (81.7%) believed that they should eliminate some products from their diets. The most often-pointed-out products were spicy and fatty foods, raw fruits and vegetables, alcohol, leguminous foods, cruciferous vegetables, dairy products and milk. Most patients (75%) modified their diets after diagnosis, and 81.7% imposed food restrictions to prevent IBD relapses.

CONCLUSIONS

The majority of patients avoided certain foods during relapses as well as to maintain remission of IBD, basing this on their own beliefs, inconsistently with current scientific knowledge. Patient education should be a key determinant in IBD control.

Pivotal Role of Intestinal Microbiota and Intraluminal Metabolites for the Maintenance of Gut-Bone Physiology

Intestinal microbiota, and their mutual interactions with host tissues, are pivotal for the maintenance of organ physiology. Indeed, intraluminal signals influence adjacent and even distal tissues. Consequently, disruptions in the composition or functions of microbiota and subsequent altered host-microbiota interactions disturb the homeostasis of multiple organ systems, including the bone. Thus, gut microbiota can influence bone mass and physiology, as well as postnatal skeletal evolution. Alterations in nutrient or electrolyte absorption, metabolism, or immune functions, due to the translocation of microbial antigens or metabolites across intestinal barriers, affect bone tissues, as well. Intestinal microbiota can directly and indirectly alter bone density and bone remodeling. Intestinal dysbiosis and a subsequently disturbed gut-bone axis are characteristic for patients with inflammatory bowel disease (IBD) who suffer from various intestinal symptoms and multiple bone-related complications, such as arthritis or osteoporosis. Immune cells affecting the joints are presumably even primed in the gut. Furthermore, intestinal dysbiosis impairs hormone metabolism and electrolyte balance. On the other hand, less is known about the impact of bone metabolism on gut physiology. In this review, we summarized current knowledge of gut microbiota, metabolites and microbiota-primed immune cells in IBD and bone-related complications.

Characterization of Intestinal Mesenchymal Stromal Cells From Patients With Inflammatory Bowel Disease for Autologous Cell Therapy

Therapy with mesenchymal stromal cells (MSCs) has shown promise in inflammatory bowel disease-leveraging their immunosuppressive and regenerative properties. However, the potential immunogenic complications of allogenic MSCs sourced from different tissues raise concern. Thus, we assessed the fitness and functionality of autologous intestinal MSCs as a potential platform for cellular therapy. Mucosal biopsy-derived MSCs from Crohn's disease (n = 11), ulcerative colitis (n = 12), and controls (n = 14) were analyzed by microscopy and flow cytometry for doubling-time, morphology, differentiation potential, and immunophenotype. Gene expression, cell-subtype composition, along with surface marker and secretome changes after IFN-γ priming were measured by bulk and single-cell RNA sequencing coupled with a 30-plex Luminex panel. MSCs expanded ex vivo demonstrate canonical MSC markers, similar growth kinetics, and tripotency regardless of the patient phenotype. Global transcription patterns were similar at baseline though inflammatory bowel disease (IBD) rectal MSCs showed changes in select immunomodulatory genes. IFN-γ priming resulted in upregulation of shared immunoregulatory genes (particularly in PD-1 signaling) and overrode the transcriptional differences observed at baseline. Furthermore, MSCs secrete key immunomodulatory molecules at baseline and in response to IFN-γ including CXCL10, CXCL9, and MCP-1. Overall, MSCs from IBD patients have normal transcriptional and immunomodulatory properties with therapeutic potential and can be sufficiently expanded.

Signaling pathways associated with bone loss in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract characterized in many patients by extraintestinal manifestations. One of the most common comorbidities seen in IBD patients is a significant reduction in their bone mass. The pathogenesis of IBD is mainly attributed to the disrupted immune responses in the gastrointestinal mucosa and putative disruptions in the gut microbiomes. The excessive inflammation of the gastrointestinal tract activates different systems, such as the RANKL/RANK/OPG and the Wnt pathways linked with bone alterations in IBD patients, thereby suggesting a multifactorial etiology. The mechanism responsible for the reduced bone mineral density in IBD patients is thought to be multifactorial, and, so far, the principal pathophysiological pathway has not been well established. However, in recent years, many investigations have increased our understanding of the effect of gut inflammation on the systemic immune response and bone metabolism. Here, we review the main signaling pathways associated with altered bone metabolism in IBD.

Risk Factors for Osteoporosis among Patients with Inflammatory Bowel Disease-Do We Already Know Everything?

INTRODUCTION

There are many known risk factors for osteoporosis (OST) among patients with inflammatory bowel disease (IBD), one of which is physical activity.

MATERIAL AND METHODS

The aim of the study is to assess the frequency and risk factors of OST among 232 patients with IBD compared to a group of 199 patients without IBD. The participants underwent dual-energy X-ray absorptiometry, laboratory tests, and completed a questionnaire about their physical activity.

RESULTS

It was found that 7.3% of IBD patients suffered from OST. Male gender, ulcerative colitis, extensive inflammation in the intestine, exacerbation of disease, rare physical activity, other forms of physical activity, past fractures, lower levels of osteocalcin, and higher levels of C-terminal telopeptide of type 1 collagen were risk factors for OST. As many as 70.6% of OST patients were rarely physically active.

CONCLUSIONS

OST is a common problem in IBD patients. OST risk factors differ significantly between the general population and those with IBD. Modifiable factors can be influenced by patients and by physicians. The key to OST prophylaxis may be regular physical activity, which should be recommended in clinical remission. It may also prove valuable to use markers of bone turnover in diagnostics, which may enable decisions regarding therapy.

Pleiotropic Effects of Vitamin D in Patients with Inflammatory Bowel Diseases

The multifaceted activity of vitamin D in patients with inflammatory bowel disease (IBD) presents a challenge for further research in this area. Vitamin D is involved in the regulation of bone mineral metabolism, it participates in the regulation of the immune system, and it is an underlying factor in the pathogenesis of IBD. Additionally, vitamin D affects Th1 and Th2 lymphocytes, influencing the release of cytokines and inhibiting tumor necrosis factor (TNF) expression and the wnt/β-catenin pathway. As far as IBDs are concerned, they are associated with microbiota dysbiosis, abnormal inflammatory response, and micronutrient deficiency, including vitamin D hypovitaminosis. In turn, the biological activity of active vitamin D is regulated by the vitamin D receptor (VDR) which is associated with several processes related to IBD. Therefore, in terms of research on vitamin D supplementation in IBD patients, it is essential to understand the metabolic pathways and genetic determinants of vitamin D, as well as to identify the environmental factors they are subject to, not only in view of osteoporosis prevention and therapy, but primarily concerning modulating the course and supplementation of IBD pharmacotherapy.

Bone Metabolism Alteration in Patients with Inflammatory Bowel Disease

Background: Metabolic bone disease is a common disorder, but there is a lack of data on it in patients with inflammatory bowel disease (IBD). Methods: In this prospective, one-centre study, we assessed bone mineral and vitamin D alterations in 187 IBD patients (119 with Crohn’s disease (CD) and 68 with ulcerative colitis (UC)). Results: While 81.3% of the patients had vitamin D deficiency, 14.2% of them had a severe deficiency. Elevated serum PTH concentrations were found in 14.9% of the patients. Only in 4.1% of cases was there an elevated level of a serum marker for bone formation (osteocalcin), whereas in 14.4% of cases, the bone resorption marker (CTX) was raised. The concentration of phosphate in urine was higher in the CD than in the UC group (51.20 vs. 31.25; p = 0.003). PTH was negatively associated with vitamin D level. Among the patients receiving corticosteroids, the CTX and CRP median levels were higher (0.49 vs. 0.38; p = 0.013 and 6.45 vs. 2.2; p = 0.029, respectively) compared with the group who did not receive them. Urine phosphate levels were lower (48.60 vs. 26.00; p = 0.005), as were osteocalcin (15.50 vs. 23.80; p < 0.001), and PTH (29.05 vs. 36.05; p = 0.018). Conclusions: Bone mineral alterations were common in patients with IBD, mostly in the CD patients. This may be associated with poor absorption, making CD patients vulnerable to changes in bone mineralization. Vitamin D supplementation remains crucial, especially when taking corticosteroids.

Overweight and abdominal fat are associated with normal bone mineral density in patients with ulcerative colitis

BACKGROUND

Low bone mineral density (BMD) is common in patients with inflammatory bowel disease. However, nutritional risk factors for low BMD in the ulcerative colitis (UC) population are still poorly understood.

AIM

To investigate the association of anthropometric indicators and body composition with BMD in patients with UC.

METHODS

This is a cross-sectional study on adult UC patients of both genders who were followed on an outpatient basis. A control group consisting of healthy volunteers, family members, and close people was also included. The nutritional indicators evaluated were body mass index (BMI), total body mass (TBM), waist circumference (WC), body fat in kg (BFkg), body fat in percentage (BF%), trunk BF (TBF), and also lean mass. Body composition and BMD assessments were performed by dual-energy X-ray absorptiometry.

RESULTS

The sociodemographic characteristics of patients with UC (n = 68) were similar to those of healthy volunteers (n = 66) (P > 0.05). Most patients (97.0%) were in remission of the disease, 58.8% were eutrophic, 33.8% were overweight, 39.0% had high WC, and 67.6% had excess BF%. However, mean BMI, WC, BFkg, and TBF of UC patients were lower when compared to those of the control group (P < 0.05). Reduced BMD was present in 41.2% of patients with UC (38.2% with osteopenia and 2.9% with osteoporosis) and 3.0% in the control group (P < 0.001). UC patients with low BMD had lower BMI, TBM, and BFkg values than those with normal BMD (P < 0.05). Male patients were more likely to have low BMD (prevalence ratio [PR] = 1.86; 95% confidence interval [CI]: 1.07-3.26). Those with excess weight (PR = 0.43; 95%CI: 0.19-0.97) and high WC (PR = 0.44; 95%CI: 0.21-0.94) were less likely to have low BMD.

CONCLUSION

Patients with UC in remission have a high prevalence of metabolic bone diseases. Body fat appears to protect against the development of low BMD in these patients.

IS DAIRY FOODS RESTRICTION MANDATORY FOR INFLAMMATORY BOWEL DISEASE PATIENTS: A MULTINATIONAL CROSS-SECTIONAL STUDY

BACKGROUND

The role of dairy foods in inflammatory bowel disease (IBD) has been controversial and it is debatable if patients with IBD should avoid milk and dairy products or not, as well as the relationship between these foods and symptoms among those population.

OBJECTIVE

This multi centric cross-sectional study designed to evaluate if it is really necessary to deprive IBD patients from consumption of dairy foods.

METHODS

A multicenter study with 12 gastroenterology referral centers in four countries was designed to evaluate gastrointestinal (GI) symptoms after consumption of dairy foods from all outpatients with IBD during 6 months and to compare patients treated at the same centers without IBD (non IBD cases).

RESULTS

Overall 1888 cases included (872 IBD patients and 1016 non IBD cases). 56.6% of participants were female with average age of 40.1 years. Racially 79.8% participants were Caucasians and originally they were citizens of 10 countries. Relative prevalence of IBD was higher in Africans and Indians and the most frequent prevalence of dairy foods intolerance was seen in Asians. Among IBD patients, 571 cases diagnosed as ulcerative colitis and 189 participants as Crohn's disease. Average duration of diagnosis as IBD was 6.8 years (from 2 months to 35 years). The most prevalent GI symptoms after consumption of all the dairy foods were bloating and abdominal pain. Totally, intolerance of dairy foods and lactase deficiency was more prevalent among IBD patients in comparison with non IBD cases (65.5% vs 46.1%, P=0.0001). But the rate of GI complains among IBD patients who had not any family history of lactase deficiency, history of food sensitivity or both were 59.91%, 52.87% & 50.33% respectively and similar to non IBD cases (P=0.68, 0.98 & 0.99 respectively).

CONCLUSION

The rate of dairy foods intolerance among IBD patients without family history of lactase deficiency or history of food sensitivity is similar to non IBD cases and probably there is no reason to deprive them from this important source of dietary calcium, vitamin D and other nutrients.

Toll-like receptor 9 deficiency induces osteoclastic bone loss via gut microbiota-associated systemic chronic inflammation

Toll-like receptors (TLRs) play pivotal roles in inflammation and provide important links between the immune and skeletal systems. Although the activation of TLRs may affect osteoclast differentiation and bone metabolism, whether and how TLRs are required for normal bone remodeling remains to be fully explored. In the current study, we show for the first time that TLR9^-/- mice exhibit a low bone mass and low-grade systemic chronic inflammation, which is characterized by the expansion of CD4⁺ T cells and increased levels of inflammatory cytokines, including TNFα, RANKL, and IL1β. The increased levels of these cytokines significantly promote osteoclastogenesis and induce bone loss. Importantly, TLR9 deletion alters the gut microbiota, and this dysbiosis is the basis of the systemic inflammation and bone loss observed in TLR9^-/- mice. Furthermore, through single-cell RNA sequencing, we identified myeloid-biased hematopoiesis in the bone marrow of TLR9^-/- mice and determined that the increase in myelopoiesis, likely caused by the adaptation of hematopoietic stem cells to systemic inflammation, also contributes to inflammation-induced osteoclastogenesis and subsequent bone loss in TLR9^-/- mice. Thus, our study provides novel evidence that TLR9 signaling connects the gut microbiota, immune system, and bone and is critical in maintaining the homeostasis of inflammation, hematopoiesis, and bone metabolism under normal conditions.

Risk Factors for Worsening of Bone Loss in Patients Newly Diagnosed with Inflammatory Bowel Disease

Background. Bone loss is common in patients with inflammatory bowel disease (IBD). The aim of the present study was to determine the prevalence of metabolic bone disease in patients newly diagnosed with IBD and to identify the risk factors for bone loss over time. Methods. We performed a retrospective, both cross-sectional and longitudinal, study to extract the risk factors of bone loss (including osteopenia and osteoporosis) in patients newly diagnosed with IBD, using dual-energy X-ray absorptiometry (DXA). Results. A total of 639 patients newly diagnosed with IBD that had at least one DXA were included in the cross-sectional study. Osteopenia and osteoporosis were diagnosed in 24.6% and 5.4% of patients, respectively. Age at diagnosis, body mass index, and serum phosphorus were identified as independent factors associated with bone loss at baseline. A total of 380 of the 639 IBD patients (including 212 CD patients and 168 UC patients) with at least a second DXA scan were included in the longitudinal study. 42.6% of the patients presented a worsening of bone loss in the follow-up study. Menopause, albumin, and use of corticosteroids were identified as independent factors associated with worsening of bone loss. Conclusions. Metabolic bone disease is common in IBD patients, and there is a significant increase in prevalence of bone loss over time. Postmenopausal female, malnourished patients, and those requiring corticosteroid treatment are at risk for persistent bone loss. Therefore, BMD measurements and early intervention with supplementation of calcium and vitamin D are recommended in IBD patients with high-risk factors.

Bone Alterations in Inflammatory Bowel Diseases: Role of Osteoprotegerin

Metabolic bone disorders are one of the most frequent extra-intestinal manifestations in patients with inflammatory bowel diseases (IBD) that might result in an increase of skeletal fragility and risk of fracture. These disorders are a consequence of bone−gut crosstalk alterations, particularly due to inflammation, which involves the RANK-RANKL-Osteoprotegerin (OPG) pathway. This cross-sectional study investigates the role of serum OPG on bone health in IBD patients. In all patients, we carried out BMD measurements at the lumbar spine and femoral neck by the dual-energy X-ray absorptiometry (DXA), and evaluation of serum OPG, 25(OH)D, and PTH. We also divided all IBD patients into two groups: group 1 consisted of premenopausal women and men younger than 50 years old, while group 2 included postmenopausal women and men aged more than 50 years old. We enrolled 36 UC patients (51%), 34 CD patients (49%), and 70 healthy controls. IBD group mean age was 44 ± 17.3 years old, with a mean disease duration of 6 years. IBD patients had a mean value of OPG of 48.1 ± 26.64 pg/mL, while mean OPG in the control group was 61.35 ± 47.19 pg/mL (p < 0.05). In group 1, there was a correlation between BMD Z-scores at the lumbar spine and femoral neck and mean OPG levels in UC subjects (r = 0.47 and r = −0.21, respectively; p < 0.05), and only between Z-score at the lumbar spine and OPG level in the CD group (r = 0.83, p < 0.05). For the patients of group 2, we report a statistically significant correlation between T-score measured at the lumbar site in both UC and CD patients (r = −0.79 and r = 0.77, respectively; p < 0.05). In our study, we demonstrated serum OPG levels to be significantly decreased in IBD subjects compared to healthy age-matched individuals. However, according to our data, it seems that the measurement of serum OPG levels is not useful to better define metabolic bone disorders in IBD patients.

Bone Fragility in Gastrointestinal Disorders

Osteoporosis is a common systemic disease of the skeleton, characterized by compromised bone mass and strength, consequently leading to an increased risk of fragility fractures. In women, the disease mainly occurs due to the menopausal fall in estrogen levels, leading to an imbalance between bone resorption and bone formation and, consequently, to bone loss and bone fragility. Moreover, osteoporosis may affect men and may occur as a sequela to different diseases or even to their treatments. Despite their wide prevalence in the general population, the skeletal implications of many gastrointestinal diseases have been poorly investigated and their potential contribution to bone fragility is often underestimated in clinical practice. However, proper functioning of the gastrointestinal system appears essential for the skeleton, allowing correct absorption of calcium, vitamins, or other nutrients relevant to bone, preserving the gastrointestinal barrier function, and maintaining an optimal endocrine-metabolic balance, so that it is very likely that most chronic diseases of the gastrointestinal tract, and even gastrointestinal dysbiosis, may have profound implications for bone health. In this manuscript, we provide an updated and critical revision of the role of major gastrointestinal disorders in the pathogenesis of osteoporosis and fragility fractures.

Crohn's disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions

BACKGROUND

Joint involvement is a common extraintestinal manifestation of Crohn's Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients.

METHODS

We retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009-2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080-0084) and split into 2 groups with or without CD (5550-5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes.

RESULTS

A total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 [95% CI 1.1-2.0] p < 0.01), acute renal failure (OR 1.7 [95% CI 1.1-2.6] p = 0.03), and pulmonary embolism (OR 2.5 [95% CI 1.3-4.6] p = 0.01).

CONCLUSION

Patients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.

Effect of sequential eradication therapy on serum osteoprotegerin levels in patients with Helicobacter pylori infection and co-existing inflammatory bowel disease

Objective

To investigate the effect of sequential Helicobacter pylori eradication therapy on serum osteoprotegerin levels in patients with H. pylori infection and co-existing inflammatory bowel disease (IBD).

Methods

Three groups of patients were involved in this observational cross-sectional study: IBD (n = 83), H. pylori infection (HP, n = 68), and H. pylori infection with co-existing IBD (HP + IBD, n = 52). These groups were compared with a normal control group (NC, n = 50). Serum osteoprotegerin, serum bone alkaline phosphatase (BALP), and fecal calprotectin (FC) levels were measured.

Results

Serum osteoprotegerin levels were significantly correlated with the simple endoscopic score for Crohn’s disease and Mayo score for ulcerative colitis. The receiver operating characteristic analysis of osteoprotegerin revealed high values for the area under the curve, sensitivity, and specificity. Discriminant analysis illustrated that osteoprotegerin levels significantly differentiated patients with IBD from healthy controls. Osteoprotegerin and FC levels distinguished the IBD and HP + IBD groups from the NC and HP groups.

Conclusions

Sequential eradication therapy did not affect serum osteoprotegerin levels in patients with H. pylori infection and co-existing IBD. Serum osteoprotegerin elevation might be a marker for IBD development in patients with past or current H. pylori infection.

Laboratory control of the osteoresorptive effects of glucorcorticoids in patients with purpose colitis

The aim of the work was to develop an informative method for laboratory monitoring of osteoresorbent action during systemic administration of glucocorticoids in patients with ulcerative colitis. The study included 54 patients with ulcerative colitis aged 18 to 44 years: 35 (64,8%) men and 19 (35,2%) women. In patients of the clinical group before and after the first, second, third courses of glucocorticosteroids, as well as during the formation of steroid dependence, the concentration of the osteoresorption marker cathepsin K was determined simultaneously in the blood serum and gingival fluid by enzyme immunoassay. The concentration of the osteomarker was compared with the parameters of the densitometric density of the lumbar vertebrae L1-L4 during X-ray examination. It was found that with the systemic use of glucocorticoids in patients with ulcerative colitis, the concentration of cathepsin K in the gingival fluid increased earlier than in the blood serum. It was found that with an increase in the concentration of cathepsin K in the gingival fluid of more than 2,6 pmol/l in conditions of systemic administration of glucocorticosteroids, the risk of osteoporosis increased with a diagnostic sensitivity of 81,8% and a specificity of 74,4% (p=0,0001).The diagnostic accuracy was 78,1%. With an increase in the concentration of cathepsin K in the gingival fluid above the differential separation level (2,6 pmol/l), the risk of developing osteoporosis increased 3,2 times (p= 0,0001). The study developed a methodological and informational algorithm has been developed for the non-invasive control of steroidal osteoporosis in patients with ulcerative colitis with systemic use of glucocorticoids by assessing the concentration of cathepsin K in the gingival fluid.

Human Relevance of Preclinical Studies on the Skeletal Impact of Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Inflammatory bowel disease (IBD) is a relapsing chronic idiopathic inflammatory condition. The increased risks of fractures in the spine and decreased BMD at all weight-bearing skeletal sites have been reported in IBD patients. The understanding of the mechanisms of IBD-induced bone loss is far from complete. Appropriate animal models are a prerequisite for studying IBD-induced bone loss, which prompted us to undertake quantitative meta-analyses by pooling data from the available IBD models that assessed various bone parameters. Sufficient data for meta-analysis are obtained from chemically- but not genetically induced models. Among the chemically induced models, only the effects of dextran sulfate sodium (DSS) and 2,4,6-trinitrobenzene sulfonic acid (TNBS) on bone parameters have been reported. Meta-analysis showed that both DSS (Hedge's g = 2.124, p = 0.001) and TNBS (Hedge's g = 6.292, p = 0.000) increased inflammatory disease severity. In pooled analysis, bone volumes in femur (Hedge's g = - 3.42, p = 0.000) and tibia (Hedge's g = - 2.49, p = 0.000) showed significant losses upon DSS administration. Similarly, bone formation rate was significantly reduced upon IBD induction (Hedge's g = - 3.495, p = 0.006). Besides, cortical thickness was reduced and trabecular microstructure deteriorated by IBD induction. Insufficient data precluded us from determining the effect of IBD on bone strength and calciotropic hormones, as well as the impact of proinflammatory cytokines on bone turnover. This meta-analysis showed that IBD induction in rodents causes significant bone loss. Impaired osteoblast function appears to be the cause of this impact.

The Risk of Osteoporosis and Osteoporotic Fracture Following the Use of Irritable Bowel Syndrome Medical Treatment: An Analysis Using the OMOP CDM Database

Patients with irritable bowel syndrome (IBS) are at increased risk of osteoporosis and osteoporotic fracture. This study investigated whether IBS medication attenuated the rate of osteoporosis and osteoporotic fracture risk. We conducted a retrospective large-scale multicenter study across eight hospital databases encoded in the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). The primary outcome was the incidence of osteoporosis, whereas secondary outcomes were osteoporotic fractures. After 1:4 matching, 24,723 IBS patients, 78,318 non-IBS patients, 427,640 non-IBS patients with IBS medication, and 827,954 non-IBS patients without IBS medication were selected. The risk of osteoporosis was significantly increased in the IBS group compared to the non-IBS group (hazard ratio (HR) 1.33; confidence interval (CI) 1.17~1.51). Even in patients who were not diagnosed with IBS, the risk of osteoporosis was significantly increased in those with IBS medication compared to those without (HR 1.77, CI 1.62~1.93). The risk of osteoporotic fracture was significantly increased in the IBS medication group (HR 1.69, CI 1.55~1.84). Patients exposed to IBS treatment even without IBS diagnosis were at increased risk of osteoporosis and osteoporotic fracture. Early diagnosis and treatment of osteoporosis should be considered in patients who have received medication for IBS symptoms.

Loss of Nckx3 Exacerbates Experimental DSS-Induced Colitis in Mice through p53/NF-κB Pathway

Inflammatory bowel diseases (IBDs) comprises a range of chronic inflammatory conditions of the intestinal tract. The incidence and prevalence of IBDs are increasing worldwide, but the precise etiology of these diseases is not completely understood. Calcium signaling plays a regulatory role in cellular proliferation. Nckx3, a potassium-dependent Na⁺/Ca²⁺ exchanger, is not only expressed in the brain but also in the aortic, uterine, and intestinal tissues, which contain abundant smooth muscle cells. This study investigated the role of Nckx3 in intestinal inflammation. Microarray analyses revealed the upregulation of the innate immune response-associated genes in the duodenum of Nckx3 knockout (KO) mice. The Nckx3 KO mice also showed an increase in IBD- and tumorigenesis-related genes. Using dextran sodium sulfate (DSS)-induced experimental colitis mice models, the Nckx3 KO mice showed severe colitis. Furthermore, the pathways involving p53 and NF-κB signaling were significantly upregulated by the absence of Nckx3. Overall, Nckx3 plays a critical role in the innate immune and immune response and may be central to the pathogenesis of IBD.

Do Only Calcium and Vitamin D Matter? Micronutrients in the Diet of Inflammatory Bowel Diseases Patients and the Risk of Osteoporosis

Osteoporosis is one of the most common extraintestinal complications among patients suffering from inflammatory bowel diseases. The role of vitamin D and calcium in the prevention of a decreased bone mineral density is well known, although other nutrients, including micronutrients, are also of extreme importance. Despite the fact that zinc, copper, selenium, iron, cadmium, silicon and fluorine have not been frequently discussed with regard to the prevention of osteoporosis, it is possible that a deficiency or excess of the abovementioned elements may affect bone mineralization. Additionally, the risk of malnutrition, which is common in patients with ulcerative colitis or Crohn's disease, as well as the composition of gut microbiota, may be associated with micronutrients status.

Association between Irritable Bowel Syndrome and Risk of Osteoporosis in Korean Premenopausal Women

OBJECTIVE

The objective of this study is to evaluate irritable bowel syndrome (IBS) as a risk factor for osteoporosis and osteoporotic fracture in Korean women after controlling for basic confounding factors and considering detailed demographic and clinical information.

SUBJECTS AND METHODS

We performed a nationwide population-based retrospective cohort analysis and matched every IBS case with a non-IBS case at a 1:4 frequency ratio based on age. The population consisted of female patients with data in the Health Insurance Review and Assessment (HIRA) database from 2002 to 2010. To determine the risk of osteoporosis and osteoporotic fracture in IBS and non-IBS patients, hazard ratios (HRs) with 95% confidence intervals (CI) were estimated using Cox proportional hazards regression models, adjusting for confounding variables, such as the area of residence, health insurance type, and economic status.

RESULTS

We identified 1,017,468 patients in the HIRA database with data from 2002 to 2010 who could potentially be included in the cohort. Among these, we identified 1,545 (11.4%) women (age >19 years) with newly diagnosed IBS (IBS group). Additionally, 6,180 patients without IBS and age-matched to the IBS group were selected. Cox modeling revealed that the crude HRs for osteoporosis and osteoporotic fractures in patients with IBS were 1.476 (95% CI, 1.241-1.754) and 1.427 (95% CI, 1.086-1.876), respectively.

CONCLUSION

Our data showed an increased incidence of osteoporosis and osteoporotic fractures in women with IBS compared with age-matched controls.

Association between non-alcoholic fatty liver disease-associated hepatic fibrosis and bone mineral density in postmenopausal women with type 2 diabetes or impaired glucose regulation

INTRODUCTION

To evaluate the association of non-alcoholic fatty liver disease (NAFLD)-associated hepatic fibrosis with bone mineral density (BMD) in postmenopausal women with type 2 diabetes mellitus (T2DM) or impaired glucose regulation (IGR).

RESEARCH DESIGN AND METHODS

Two cohorts including 46 subjects with biopsy-proven NAFLD and 445 subjects with proton magnetic resonance spectrum-proven NAFLD were enrolled in this study. All subjects were postmenopausal women with T2DM or IGR. BMD at the lumbar spine L1-L4 and hip was measured using dual-energy X-ray absorptiometry. NAFLD fibrosis stage and NAFLD fibrosis score were used to evaluate the severity of liver fibrosis.

RESULTS

In subjects with liver biopsy-proven NAFLD, BMD (T-score, Z-score and BMD value) in the advanced fibrosis group were significantly lower than that in the non-advanced fibrosis group (p<0.05). Fibrosis stage was negatively associated with T-score, Z-score and BMD value after adjusting for age, body mass index (BMI) and fasting plasma glucose (FPG). Additionally, fibrosis stage was independently associated with T-score, Z-score and BMD value after adjusting for age, BMI and FPG. These results were validated in a large cohort of 445 subjects. Additionally, bone metabolism-associated factors, including calcium and phosphate, were associated with liver fibrosis, indicating that bone metabolism may play a critical role in the association between liver fibrosis and BMD. Mechanically, parathyroid hormone and biomarkers of bone formation (osteocalcin and procollagen type 1 N-terminal propeptide) and bone resorption (procollagen type I carboxy terminal peptide β special sequence) were increased in subjects with advanced liver fibrosis than in subjects without advanced liver fibrosis, indicating that liver fibrosis decreased BMD probably via increasing bone turnover.

CONCLUSIONS

NAFLD-associated hepatic fibrosis was negatively associated with decreased BMD in postmenopausal women with T2DM or IGR. Liver fibrosis decreased BMD probably via increasing bone turnover. Severe liver fibrosis may represent high risk for osteoporosis in postmenopausal women with T2DM or IGR.

Vitamin C Deficiency and the Risk of Osteoporosis in Patients with an Inflammatory Bowel Disease

Recent research studies have shown that vitamin C (ascorbic acid) may affect bone mineral density and that a deficiency of ascorbic acid leads to the development of osteoporosis. Patients suffering from an inflammatory bowel disease are at a risk of low bone mineral density. It is vital to notice that patients with Crohn’s disease and ulcerative colitis also are at risk of vitamin C deficiency which is due to factors such as reduced consumption of fresh vegetables and fruits, i.e., the main sources of ascorbic acid. Additionally, some patients follow diets which may provide an insufficient amount of vitamin C. Moreover, serum vitamin C level also is dependent on genetic factors, such as SLC23A1 and SLC23A2 genes, encoding sodium-dependent vitamin C transporters and GSTM1, GSTP1 and GSTT1 genes which encode glutathione S-transferases. Furthermore, ascorbic acid may modify the composition of gut microbiota which plays a role in the pathogenesis of an inflammatory bowel disease.

Longitudinal changes in bone mineral density in children with inflammatory bowel diseases

AIM

Children with inflammatory bowel disease (IBD) are prone to low bone mineral density (BMD). Our aim was to assess longitudinal changes in BMD in this population.

METHODS

A retrospective longitudinal study of children with IBD, treated at two tertiary centres in Israel, who underwent two BMD measurements by dual-energy X-ray absorptiometry (DXA). Changes in lumbar spine BMD (∆L1-4 z-scores) were examined for correlations with clinical characteristics.

RESULTS

The cohort included 41 patients (age at diagnosis 12.1 ± 3.5 years, 23 females).The mean interval between the scans was 3.4 ± 2.0 years. There was a trend towards improvement in L1-4 z-scores (-1.64 ± 1.02 vs -1.45 ± 0.83, P = .12). ∆L1-4 z-scores correlated positively with ∆weight-standard deviation scores (SDS), ∆height-SDS and ∆BMI-SDS, and with age at the second scan (R = .55, P < .01; R = .42, P < .01; R = .42, P = .01; R = .35, P = .02, respectively); and negatively with L1-4 z-scores at the first scan (R = -.63, P < .01). Stepwise linear regression analysis identified the first scan L1-4 z-scores and ∆weight-SDS as independent predictors of ∆L1-4 z-scores. An L1-4 z-score ≤-2 at the first DXA scan was associated with significant improvement at the second scan.

CONCLUSION

Improvement in BMD was more pronounced in children who gained weight or whose BMD was low at the first scan.

Effects of an Omega-3 and Vitamin D Supplement on Fatty Acids and Vitamin D Serum Levels in Double-Blinded, Randomized, Controlled Trials in Healthy and Crohn's Disease Populations

Two trials separately measured the bioavailability and impact on inflammation of a supplement taken daily containing 510 mg Docosahexaenoic acid (DHA), 344 mg Eicosapentaenoic acid (EPA), and 1000 IU of vitamin D (25-hydroxyvitamin D; 25(OH)D), for healthy and Crohn’s disease (CD) populations. Both trials were double blinded, randomized, placebo-controlled with cross-over. Participants were randomly allocated to groups A (placebo then supplement) or B (supplement then placebo). Both included a washout. Fatty acid (N-3 PUFAs) and vitamin D serum levels, plasma C-reactive protein (CRP), and stool calprotectin were measured before and after each treatment period. Outcome measures were analyzed using generalized linear mixed models, including terms for treatment, period, and a treatment-by-period interaction. The supplement significantly increased serum levels in healthy and CD groups for EPA (p < 0.001 and p < 0.001, respectively), Docosapentaenoic acid (p < 0.001 and 0.005), DHA (p < 0.001 and 0.006), the omega-3 index (p < 0.001 and 0.001), and (vitamin D (p < 0.001 and 0.027). CRP and calprotectin measures showed no evidence of a treatment effect on inflammation; however, model estimation was imprecise for both outcomes, hence further research is required to elucidate potential inflammation effects. The nutrient supplement increased serum levels of key N-3 PUFAs and vitamin D in both populations, showing the preparation was readily bioavailable.

Do Patients Older Than 60 Years With Inflammatory Bowel Disease Have More Vertebral Fractures Than Age-matched Controls? A Study Using Abdominal and Pelvic CT Scans With Sagittal Reformatting as Screening Tool

INTRODUCTION

It is undetermined whether patients with inflammatory bowel diseases (IBDs) have increased prevalence of vertebral compression fractures (VCFs) since many VCFs are asymptomatic and radiographs may overlook them. We compared the prevalence of VCFs in patients older than 60 years with and without IBDs.

METHODS

We studied 55 patients with IBDs and 165 controls who underwent CT scans for nonspinal conditions. We evaluated the presence of VCFs, fracture severity using the Genant score, and we determined whether age, sex, diagnosis of IBD, treatment, and time since diagnosis were associated with VCFs. Using logistic regression analysis, we assessed the independent effect of each variable.

RESULTS

Mean age was 72.7 years; 165 patients (75%) were women. Thirty-five patients (16%) had at least one VCF (16.4% IBD; 15.8% controls, P = 0.92); both groups exhibited similar fracture severity. Patients with VCFs were older than patients without VCFs (79.8 versus 70.2, P < 0.01 IBD; 76.4 versus 72.4, P = 0.02 controls). No other clinical variables were different in patients with and without VCFs in either cohort. Only age was independently associated with VCFs in both cohorts.

DISCUSSION

VCFs were not more frequent or severe in patients older than 60 years with IBD presented than in age-matched controls.

Azathioprine Has a Deleterious Effect on the Bone Health of Mice with DSS-Induced Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) often present poor bone health and are 40% more at risk of bone fracture. Studies have implicated autophagy in IBD pathology and drugs used to treat IBD stimulate autophagy in varying degrees, however, their effect on the skeleton is currently unknown. Here, we have utilised the dextran sulphate sodium (DSS) model of colitis in mice to examine the effects of the thiopurine drug azathioprine on the skeleton. Ten-week-old male mice (n = 6/group) received 3.0% DSS in their drinking water for four days, followed by a 14-day recovery period. Mice were treated with 10 mg/kg/day azathioprine or vehicle control. Histopathological analysis of the colon from DSS mice revealed significant increases in scores for inflammation severity, extent, and crypt damage (p < 0.05). Azathioprine provided partial protection to the colon, as reflected by a lack of significant difference in crypt damage and tissue regeneration with DSS treatment. MicroCT of vehicle-treated DSS mice revealed azathioprine treatment had a significant detrimental effect on the trabecular bone microarchitecture, independent of DSS treatment. Specifically, significant decreases were observed in bone volume/tissue volume (p < 0.01), and trabecular number (p < 0.05), with a concurrent significant increase in trabecular pattern factor (p < 0.01). Immunohistochemical labelling for LC3 revealed azathioprine to induce autophagy in the bone marrow. Together these data suggest that azathioprine treatment may have a deleterious effect on IBD patients who may already be at increased risk of osteoporotic bone fractures and thus will inform on future treatment strategies for patient stratification.

Oncostatin M as a new diagnostic, prognostic and therapeutic target in inflammatory bowel disease (IBD)

Introduction: Given the high rate of primary and acquired resistance to current inflammatory bowel disease (IBD) treatments, novel drug targets and biomarkers that aid in therapeutic prediction are eagerly awaited. Furthermore, postponing treatment initiation because of a diagnostic delay profoundly affects patient well-being and overall disease evolution. Among the emerging targets and biomarkers, oncostatin M (OSM) has gained much interest in the past few years.Areas covered: A literature search to June 2019 was performed to identify the most relevant reports on Oncostatin M. The authors summarize the biology of OSM, its role in health and disease, its potential as a diagnostic, prognostic and therapeutic biomarker in the field of IBD and how it might be a drug target of the future.Expert opinion: OSM has diagnostic, prognostic and therapeutic capabilities. High mucosal OSM predicts primary non-response to anti-TNF antibodies. However, one could question whether a single cytokine can capture the complexity and heterogeneity of IBD. Neutralizing OSM in patients with elevated mucosal OSM appears to be attractive and should be considered as a valid option for the first biomarker-stratified, proof-of-concept trial that studies a novel therapeutic compound in IBD.

Improving bone mineral density screening in patients with inflammatory bowel disease: a quality improvement report

The prevalence of osteopenia and osteoporosis in patients with inflammatory bowel disease (IBD) is estimated between 17% and 41%, partly due to repeat courses of glucocorticoids which enhance the risk for bone disease. Multiple gastroenterological and endocrine societies have established guidelines for bone mineral density (BMD) screening in patients with IBD, with estimates suggesting providers vary in their adherence. We aimed to improve the rate of BMD screening in patients with IBD in a large academic outpatient practice. Using the Plan-Do-Study-Act (PDSA) model, we first conducted a retrospective review and determined that only 10.8% of patients with IBD in our practice were adequately undergoing BMD screening. Over the course of five PDSA cycles, we conducted three interventions focusing on education and provider reminders. Through an informative lecture, a flyer and an electronic medical record-based prompt, we were able to increase our rate of BMD screening to 81.8%. Current rates of BMD screening in patients with IBD are not adequate. We demonstrate a simple quality improvement initiative that successfully improved our adherence to standards of practice.

Risk of Fractures in Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis

BACKGROUND

Studies assessing the risk of fractures in inflammatory bowel diseases (IBD) have shown controversial results.

GOALS

We performed a systematic review and meta-analysis to assess the risk of fractures in IBD.

STUDY

Electronic databases were searched for cohort studies assessing the risk of fractures in IBD. The outcomes were the risk of overall fractures and at specific sites, and the association between the risk of fractures and the proportion of patients with corticosteroid use or osteoporosis.

RESULTS

Ten studies including 470,541 patients were identified. The risk of overall fractures in IBD patients was similar to controls [odds ratio (OR), 1.08; P=0.70; 95% confidence interval (CI), 0.72-1.62) with moderate heterogeneity (I=74.4%) which appeared to be due to the variable power and outcomes among the studies. The OR of fractures at the spine was significantly elevated at 2.21 (P<0.0001; 95% CI, 1.39-3.50) with low heterogeneity (I=26.1%). Meta-regression showed a correlation with the proportion of patients with steroid use. Risks of fractures at other sites (hip, rib, and wrist) were not elevated. Patients with fractures were more commonly on steroids compared with those without fractures (OR, 1.47; P=0.057; 95% CI, 0.99-2.20; I<0.0001%), but there was no correlation with osteoporosis.

CONCLUSIONS

IBD patients had no increased risk of overall fractures, but were at significantly increased risk of fractures at the spine, which was associated with steroid use. Strict surveillance and prevention of spine fractures are indicated in patients with IBD.

Effect of mineral status and glucocorticoid use on bone mineral density in patients with Crohn's disease

OBJECTIVES

Crohn's disease (CD) is a condition that is characterized by chronic inflammation. The presence of multifactorial pathogenesis that results from inflammation is associated with low micronutrient consumption and glucocorticoid use, which may be related to bone health. This study aimed to evaluate the relationship between dietary mineral intake and glucocorticoid use in bone mineral density (BMD) in patients with CD.

METHODS

A cross-sectional study of 62 patients with CD ages 20 y to 40 y measured their macro- and micronutrient intake with a 3-d food record. The lumbar spine and femoral neck BMDs were determined using a bone densitometry technique. The C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) values were also noted.

RESULTS

Dietary intake of calcium, zinc, and magnesium was below the reference values but the phosphorus intake level was within the normal value range. Patients with osteopenia and osteoporosis accounted for 17.7% and 14.5%, respectively, of the total number of participants. Significant bone loss was found in 22.6% of patients taking glucocorticoid medications. BMD was significantly reduced and also observed in patients in the active phase of their disease. Zinc and calcium intakes were found to be correlated with reduced femoral neck BMD. The mean CRP and ESR values were above the normal ranges. Significant differences in age and ESR were observed between patients with normal and reduced BMD (P <0.05).

CONCLUSIONS

Low calcium and zinc intake, glucocorticoid use, and active disease phase are favorable conditions for bone loss in patients with Crohn's disease.

Pediatric-onset inflammatory bowel disease poses risk for low bone mineral density at early adulthood

BACKGROUND

Inflammatory bowel disease (IBD) is known to pose a risk for low bone mineral density (BMD) in children and adults. We aimed to evaluate the impact of pediatric-onset IBD on BMD in adulthood.

METHODS

Records of pediatric-IBD patients were retrospectively reviewed for documentation of dual-energy X-ray absorptiometry (DXA) scans in adulthood. BMD was expressed as z-score.

RESULTS

Sixty one patients were included. Mean (±SD) age at diagnosis was 14.7 (±2.4) years. Mean age at first DXA scan in adulthood was 23.9 years (±4.8). Median BMD z-score was -1.2 SD (IQR, -1.8 to -0.4), significantly lower than expected in normal population (p<0.001). Osteopenia (BMD z-score ≤-1 SD) was noted in 44.3% (n=27), and osteoporosis (BMD z-score ≤-2.5 SD) in 8.2% (n=5). Bone-status showed no correlation with age, disease severity, vitamin D status at diagnosis, IBD subtype or duration of disease. Positive correlation (r=0.306) was identified between low weight z-score at diagnosis and abnormal bone-status in adulthood. Among 36 patients with multiple DXA scans, there was no significant change in BMD during follow-up of 2.4 years.

CONCLUSIONS

Osteopenia and osteoporosis are frequent in adult IBD patients with pediatric-onset disease and correlates with low weight z-score at diagnosis.

The Use of the Fracture Risk Assessment (FRAX®) Tool in Predicting Risk of Fractures in Patients With Inflammatory Bowel Disease: A Systematic Review

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is associated with an increased prevalence of osteoporosis and osteopenia. We aim to evaluate the use of the World Health Organization Fracture Risk Assessment (FRAX®) tool in these patients to assess 10-yr risk of fracture. Electronic searches were performed with key words relating to IBD and FRAX in the MEDLINE, EMBASE, and SCOPUS databases. Summary estimates were calculated. A fixed or random-effects model was used depending on heterogeneity (I²). The search yielded 146 references; 7 that included research carried out in adult patients, were used in the systematic review and quantitative summary. No significant publication bias was noted according to the Harbord test. The 10-yr probability of hip and major osteoporotic fracture in adult IBD patients was 1.03% (95% confidence interval [CI]: 0.37%-2%; I² = 0%) and 4.05% (95% CI: 2.61%-5.79%; I² = 49%), respectively. In those patients with Crohn's disease, hip and major osteoporotic fractures calculated with FRAX increased to 1.74% (95% CI: 0.42%-3.93%; I² = 37.5%) and 6.65% (95% CI: 2.97%-11.66%; I² = 8.7%), respectively. Risks of fracture in adults with ulcerative colitis were provided by a single study only. The FRAX tool has been limitedly used in patients with IBD; however, the evidence currently available only shows a modest increase in the 10-yr risks of bone fracture and does not support unequivocally the need for specific interventions. Further well-designed studies are needed to confirm the results obtained from this systematic review.

Assessment of corticosteroid-related quality of care measures for ulcerative colitis and Crohn's disease in the United States: a claims data analysis

OBJECTIVE

To evaluate corticosteroid (CS)-related quality of care indicators in patients with ulcerative colitis (UC) and Crohn's disease (CD) in the US.

METHODS

Adults diagnosed with UC or CD and prescription fills for an oral CS were identified from a large commercial US claims database (2005-2013). Quality indicators included prolonged CS use (≥60 days), use of CS-sparing therapy, and bone loss assessment. State-level variations in quality of care indicators were estimated using logistic regression models adjusting for age, gender, insurance plan type, and CD severity.

RESULTS

Of the 25,063 UC and 22,155 CD patients receiving CS, 16.1% and 12.6%, respectively, were prolonged CS users. Among prolonged CS users, 52.5% of UC and 68.2% of CD patients used CS-sparing therapy. Bone loss assessment was observed in 11.0% of UC patients with prolonged CS use and 7.7% of newly diagnosed CD patients. Prolonged CS use was the lowest in Kentucky (odds ratio [OR] = 0.59) and the highest in Wisconsin (OR = 1.41) for UC patients; the lowest in North Carolina and New York (both OR = 0.71) and the highest in Utah (OR = 2.42) for CD patients. CS-sparing therapy use was the lowest in Delaware (OR = 0.42) and the highest in Michigan (OR = 0.83) for UC patients; it was significantly different only in South Carolina (OR = 0.57) for CD patients. Bone loss assessment rates were the highest in Arizona (OR = 1.83) for UC patients and were the lowest in Mississippi (OR = 0.52) and the highest in Texas (OR = 1.51) for CD patients.

LIMITATIONS

Information on disease severity was not available in the database.

CONCLUSIONS

Significant regional variations in all three quality indicators were observed across the US.

Bone Loss Prevention of Bisphosphonates in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to evaluate the effect of bisphosphonates in improving bone mineral density (BMD) and decreasing the occurrence rate of fractures and adverse events in patients with inflammatory bowel disease (IBD).

METHODS

Randomized controlled trials (RCTs) which use bisphosphonates in IBD patients were identified in PubMed, MEDLINE database, EMBASE database, Web of Knowledge, and the Cochrane Databases between 1990 and June 2016. People received bisphosphonate or placebos with a follow-up of at least one year were also considered. STATA 12.0 software was used for the meta-analysis.

RESULTS

Eleven randomized clinical trials were included in the meta-analysis. The data indicated that the percentage change in the increased BMD in the bisphosphonates groups was superior to that of the control groups at the lumbar spine and total hip. At the femoral neck, there was no significant difference between the two groups. The incidence of new fractures during follow-up showed significant reduction. The adverse event analysis revealed no significant difference between the two groups.

CONCLUSION

Our results demonstrate that bisphosphonates therapy has an effect on bone loss in patients with IBD but show no evident efficiency at increasing the incidence of adverse events.

Expression of Cav1.3 calcium channel in the human and mouse colon: posttranscriptional inhibition by IFNγ

It has been hypothesized that apically expressed L-type Ca²⁺ channel Ca_v1.3 (encoded by CACNA1D gene) contributes toward an alternative TRPV6-independent route of intestinal epithelial Ca²⁺ absorption, especially during digestion when high luminal concentration of Ca²⁺ and other nutrients limit TRPV6 contribution. We and others have implicated altered expression and activity of key mediators of intestinal and renal Ca²⁺ (re)absorption as contributors to negative systemic Ca²⁺ balance and bone loss in intestinal inflammation. Here, we investigated the effects of experimental colitis and related inflammatory mediators on colonic Ca_v1.3 expression. We confirmed Ca_v1.3 expression within the segments of the mouse and human gastrointestinal tract. Consistent with available microarray data (GEO database) from inflammatory bowel disease (IBD) patients, mouse colonic expression of Ca_v1.3 was significantly reduced in trinitrobenzene sulfonic acid (TNBS) colitis. In vitro, IFNγ most potently reduced Ca_v1.3 expression. We reproduced these findings in vivo with wild-type and Stat1^-/- mice injected with IFNγ. The observed effect in Stat1^-/- suggested a noncanonical transcriptional repression or a posttranscriptional mechanism. In support of the latter, we observed no effect on the cloned Ca_v1.3 gene promoter activity and accelerated Ca_v1.3 mRNA decay rate in IFNγ-treated HCT116 cells. While the relative contribution of Ca_v1.3 to intestinal Ca²⁺ absorption and its value as a therapeutic target remain to be established, we postulate that Ca_v1.3 downregulation in IBD may contribute to the negative systemic Ca²⁺ balance, to increased bone resorption, and to reduced bone mineral density in IBD patients.

Variation in inflammatory bowel disease care among saudi pediatric gastroenterologists

BACKGROUND/AIM

Although international guidelines in inflammatory bowel disease (IBD) management are currently available, variations in IBD care still exist. The aim of this study was to determine the extent of the variation in IBD care among Saudi pediatric gastroenterologists.

MATERIALS AND METHODS

A cross-sectional survey was conducted among all pediatric gastroenterologists who were members of the Saudi Society of Pediatric Gastroenterology, Hepatology, and Nutrition (SASPGHAN) from August 2015 to December 2015. The questionnaire included items on demographic characteristics and utilization of different diagnostic and therapeutic interventions in IBD care.

RESULTS

Of the 45 registered pediatric gastroenterologists surveyed, 37 (82%) returned the survey from 20 centers across the country; 75.7% were practicing in tertiary care centers. There was a considerable variation in the use of different diagnostic tests during the initial evaluation of the disease. Utilization of calprotectin assays, magnetic resonance imaging enterography, and bone densitometry seemed to vary the most between physicians practicing at tertiary and secondary care centers. There were statistically significant differences in the prescription of biological therapy between the two groups.

CONCLUSIONS

We found a considerable variation in the use of different diagnostic and therapeutic interventions in the management of pediatric IBD patients. Such variations could lead to unintended differences in patient outcomes. Implementation of the available evidence-based guidelines may limit such variations and ultimately could improve the quality of IBD care provided.

Emerging Roles for Noncanonical NF-κB Signaling in the Modulation of Inflammatory Bowel Disease Pathobiology

Crohn's disease and ulcerative colitis are common and debilitating manifestations of inflammatory bowel disease (IBD). IBD is characterized by a radical imbalance in the activation of proinflammatory and anti-inflammatory signaling pathways in the gut. These pathways are controlled by NF-κB, which is a master regulator of gene transcription. In IBD patients, NF-κB signaling is often dysregulated resulting in overzealous inflammation. NF-κB activation occurs through 2 distinct pathways, defined as either canonical or noncanonical. Canonical NF-κB pathway activation is well studied in IBD and is associated with the rapid, acute production of diverse proinflammatory mediators, such as COX-2, IL-1β, and IL-6. In contrast to the canonical pathway, the noncanonical or "alternative" NF-κB signaling cascade is tightly regulated and is responsible for the production of highly specific chemokines that tend to be associated with less acute, chronic inflammation. There is a relative paucity of literature regarding all aspects of noncanonical NF-ĸB signaling. However, it is clear that this alternative signaling pathway plays a considerable role in maintaining immune system homeostasis and likely contributes significantly to the chronic inflammation underlying IBD. Noncanonical NF-κB signaling may represent a promising new direction in the search for therapeutic targets and biomarkers associated with IBD. However, significant mechanistic insight is still required to translate the current basic science findings into effective therapeutic strategies.