Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines)
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Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines)
Athos Bousvaros MD, MPHBoston Children’s Hospital
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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
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Bone mass is acquired in childhood and adolescence
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Causes of low bone density in IBD patients
Inflammation
Low muscle mass
Glucocorticoids
Delayed puberty
Hypovitaminosis D
Delayed growth
Protein-calorie malnutrition
GENETICS
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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
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Which recommendations to follow?THESE – Screen and treat
Journal Pediatric GI and Nutrition 2011; 11-25
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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
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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
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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
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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
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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
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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