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Ted Denson, MD

How Should W e M onitor , Prevent , and Treat O steoporosis in IBD? All of Our IBD Patients are at Risk and Therefore all Should Begin Treatment at Diagnosis. Ted Denson, MD Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine. Disclosures.

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Ted Denson, MD

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  1. How Should We Monitor, Prevent, and Treat Osteoporosis in IBD?All of Our IBD Patients are at Risk and Therefore all Should Begin Treatment at Diagnosis Ted Denson, MD Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine

  2. Disclosures • Grant support: NIH & CCFA

  3. Bone Health in Children with IBD • Bone mineral density (BMD) is often reduced in children with IBD • Low trauma and vertebral compression fractures can occur • Does low BMD predict future fractures in children with IBD? • Does DXA measurement of BMD predict future fractures in children with IBD? • How does DXA measurement of low BMD affect clinical management? Sylvester, Inflamm Bowel Dis 2005; 11:1020-3

  4. Screening for Risk of Fractures Goal of noninvasive skeletal testing is to identify children at risk for low trauma fractures; fracture threshold not well defined Bachrach,EndocrinolMetabClin North Am 2005; 34:521-35

  5. Which IBD Patients Should Have DXA Performed? “All children with IBD who can lie on a cushioned table for 15 to 20 minutes should have a DXA scan.” “Therapeutic interventions should not be instituted on the basis of a single DXA measurement.” Pappa et al, JPGN 2012

  6. Limitations of DXA • Bone resistance to fracture: bone mass, geometry, quality, and material properties • DXA does not measure volumetric bone mineral density; estimated from 2D measurement • DXA does not measure bone geometry • DXA does not distinguish between cortical and trabecular bone • QCT and pQCT capture these measures but are limited by cost, radiation, and normative values Bachrach, Endocrinol Metab Clin North Am 2005; 34:521-35

  7. DXA Overestimates Low BMD Compared to QCT “The inability of DXA to to account for the large variability in skeletal size and body composition in growing children greatly diminishes the accuracy in the pediatric population ” Wren et al, J Peds 2005

  8. Pitfalls in the DXA Interpretation • PA lumbar spine preferred site • Always use age & gender Z-score & pediatric norms, never T-score (reflects adult peak bone mass) • DXA underestimates vBMD in children with reduced height for age • Need to account for height Z-score and delayed bone age • A Z-score < -2 = “low bone mineral density for age”, not osteoporosis • A low Z-score by itself should not be a reason to start anti-resorptive(bisphosphonate) treatment; low trauma fracture a better indication Bachrach, Endocrinol Metab Clin North Am 2005; 34:521-35

  9. Accounting for Delayed Bone Age in DXA Bachrach,EndocrinolMetabClin North Am 2005; 34:521-35

  10. DXA Results and Risk of Fracture 6213 healthy children with DXA at age 9.9 followed for two years 550 (8.9%) with at least one fracture “Weak inverse relationship between BMD at 9.9 years and subsequent fracture risk: OR per SD decrease: 1.12(1.02-1.25)” Clark et al, JBMR 2006

  11. Most Adult CD Patients with Vertebral Fractures have Normal BMD Siffledeen et al, Clin Gastro Hep 2007

  12. Inflammatory Markers and PTH are Associated with Vertebral Compression Fractures in Adult CD “BMD screening on its own is not sufficient to predict the onset of metabolic bone disease in this population” “Hypothesis: inflammation induces microarchitectural changes in trabecular bone” Siffledeen et al, Clin Gastro Hep 2007

  13. Effective IBD Therapy Addresses the Pathogenesis of Bone Disease Nutrition Calcium, vitamin D Caloric/Protein intake Vitamin K Micronutrients Immune Factors T cells (INF-γ, RANKL) TNFa, IL-6 Delayed sexual maturation IGF-I Inactivity Lean tissue mass Medications Modeling Remodeling Bone formation Endochondral Periosteal Bone resorption Faster Uncoupled Coupled Bone formation Slower Bone resorption Endosteal Bone reshaping and growth Maintenance of bone mass Sylvester, Inflamm Bowel Dis 2005; 11:1020-3

  14. Bone Health in Children with IBD • Bone mineral density (BMD) is often reduced in children with IBD and may reduce peak bone mass in adulthood. • Low trauma and vertebral compression fractures can occur, particularly in adulthood. • Low BMD does not reliably predict future fractures in children or adults with IBD – most who fracture have normal BMD. • DXA measurement of BMD does not reliably estimate bone strength or predict future fractures. • DXA measurement of BMD has modest impact upon clinical managementbeyond nutritional and medical therapy already offered to all patients.

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