Osteosarcopenia in autoimmune cholestatic liver diseases: Causes, management, and challenges

Table 2 General expert recommendations for management of osteosarcopenia in patients with cholestatic liver diseases

Risk for osteoporosis should be considered in all patients with cholestatic liver diseases
DXA should be considered to assess BMD at presentation and at follow-up where indicated	T-score > -1.5 - > repeat in 2-3 yr
	Osteopenia, T-score ≤ -1.5 but > -2.5, or presence of risk factors - > repeat in 1-2 yr
	Osteoporosis, T score ≤ -2.5, or pathological fractures with normal BMD - > repeat in one year
VFs should be investigated at presentation with lateral spine X-rays radiograph in all patients with cholestatic liver diseases
Alcohol and smoking cessation in addition to increasing aerobic exercise and practicing routine weight-bearing exercises are highly recommended in all patients with cholestatic liver diseases
Consider including supplements of 25-(OH)-vitamin D (800 IU daily) and calcium (1000–1500 mg daily) in patients with cholestatic liver disease and osteopenia or osteoporosis
Consider utilizing bisphosphonates in patients with osteoporosis and patients with VFs, regardless of underlying disease and BMD values
For patients with PBC, denosumab might have a beneficial role both for osteoporosis treatment and for PBC but data are scarce, and recommendation cannot be made yet
Consider evaluating sarcopenia by cross-sectional imaging when strong clinical suspicion is present in all patients with cholestatic liver diseases
Consider exercise programs and adequate nutritional and caloric intake in all patients with sarcopenia and cholestatic liver diseases

DXA: Dual-energy X-ray absorptiometry; BMD: Bone mineral density; VFs: Vertebral fractures; PBC: Primary biliary cholangitis.