Post on 23-Feb-2016
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Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines)
Athos Bousvaros MD, MPHBoston Children’s Hospital
Disclosures
• Consulting: Milennium, Dyax, Cubist, Nutricia• Research support: Prometheus, Merck• With gratitude to Helen Pappa, Francisco
Sylvester, and the NASPGHAN Skeletal Health working guideline.
JPGN 2011
Bone mass is acquired in childhood and adolescence
Causes of low bone density in IBD patients
Inflammation
Low muscle mass
Glucocorticoids
Delayed puberty
Hypovitaminosis D
Delayed growth
Protein-calorie malnutrition
GENETICS
How to approach the issue of low bone mineral density in pediatric IBD
• Ignore it• Treat everybody• Screen and treat those
who need to be treated
Which recommendations to follow?THESE – Screen and treat
Journal Pediatric GI and Nutrition 2011; 11-25
Who to get DEXA on?–Growth failure • Height Z score <-2.0 SD• BMI <2.0 SD
–Primary or secondary amenorrhea– Severe inflammatory disease, esp.
hypoalbuminemia–> 6 months of steroid therapy–Clinically significant fractures
What kind of DEXA to get
• Children under 14 years –Total body and spine
• Children 14 and over–Hip and spine
• Cost under $150*
*healthcarebluebook.com
Who and when to get a 25 hydroxy vitamin D level on?
• Everyone– African American children at higher risk*
• Once a year, in the winter (cost-$30)• If low (<32 ng/ml), treat:– 50,000 units once a week for 10 weeks– Ensure adequate calcium intake during this
period
*Middleton, JPGN 2013; 57:587
Why screen and treat?
• Not everyone needs to be treated.• 60-70% of children with IBD will have a
NORMAL BMD Z score • Low bone mineral density may change
your therapeutic decisions– Additional data in patient decision making– Use steroid sparing agents (e.g. infliximab)– Implement nutritional therapy faster– More rigorous diet/exercise program– Referral to endocrinologist
TREAT Don’t treat
Why screen and treat?
• Adherence, adherence, adherence!!!!– Approximately 70% of medication doses
(ASA and thiopurine) are taken by children– Approximately 25% of adolescents take
over 80% of their prescribed ASA doses– Approximately 15% of adolescents take
their prescribed thiopurine doses.• Calcium and vitamin D = 2-3 extra tabs
per day (cost $40/year)
Leleiko IBD Journal 2013;19:832
Summary: Screen and treat
• Prevention of osteoporosis is important• Not everyone needs to be screened– Focus on the high risk groups
• Not everyone needs to be treated– Treat those with BMD Z score <-1.0
• Treat suboptimal BMD like an extraintestinal manifestation of IBD– Control inflammation, optimize nutrition– Follow up, and monitor adherence