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