Topic Highlight
Copyright ©2014 Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2014; 20(39): 14087-14098
Published online Oct 21, 2014. doi: 10.3748/wjg.v20.i39.14087
Managing osteoporosis in ulcerative colitis: Something new?
Luca Petruccio Piodi, Alessandro Poloni, Fabio Massimo Ulivieri
Luca Petruccio Piodi, Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico of Milan, 2nd Gastroenterology Unit, 20122 Milan, Italy
Alessandro Poloni, Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Radiology Unit, 20097 San Donato Milanese, Italy
Fabio Massimo Ulivieri, Fondazione Irccs Ca' Granda Ospedale Maggiore Policlinico, Nuclear Medicine, Bone Metabolic Unit, 20122 Milan, Italy
Author contributions: Piodi LP contributed to concept, write and revise the article; Poloni A contributed in acquisition of data and to draft the article; Ulivieri FM contributed to concept, write and revise the article.
Correspondence to: Fabio Massimo Ulivieri, MD, Fondazione Irccs Ca' Granda Ospedale Maggiore Policlinico, Nuclear Medicine, Bone Metabolic Unit, via F.Sforza 35, 20122 Milan, Italy. ulivieri@gmail.com
Telephone: +39-2-55033529 Fax:+39-2-55034382
Received: March 8, 2014
Revised: May 12, 2014
Accepted: June 26, 2014
Published online: October 21, 2014
Processing time: 225 Days and 21.9 Hours
Abstract

The authors revise the latest evidence in the literature regarding managing of osteoporosis in ulcerative colitis (UC), paying particular attention to the latest tendency of the research concerning the management of bone damage in the patient affected by UC. It is wise to assess vitamin D status in ulcerative colitis patients to recognize who is predisposed to low levels of vitamin D, whose deficiency has to be treated with oral or parenteral vitamin D supplementation. An adequate dietary calcium intake or supplementation and physical activity, if possible, should be guaranteed. Osteoporotic risk factors, such as smoking and excessive alcohol intake, must be avoided. Steroid has to be prescribed at the lowest possible dosage and for the shortest possible time. Moreover, conditions favoring falling have to been minimized, like carpets, low illumination, sedatives assumption, vitamin D deficiency. It is advisable to assess the fracture risk in all UC patient by the fracture assessment risk tool (FRAX® tool), that calculates the ten years risk of fracture for the population aged from 40 to 90 years in many countries of the world. A high risk value could indicate the necessity of treatment, whereas a low risk value suggests a follow-up only. An intermediate risk supports the decision to prescribe bone mineral density (BMD) assessment and a subsequent patient revaluation for treatment. Dual energy X-ray absorptiometry bone densitometry can be used not only for BMD measurement, but also to collect data about bone quality by the means of trabecular bone score and hip structural analysis assessment. These two indices could represent a method of interesting perspectives in evaluating bone status in patients affected by diseases like UC, which may present an impairment of bone quality as well as of bone quantity. In literature there is no strong evidence for instituting pharmacological therapy of bone impairment in UC patients for clinical indications other than those that are also applied to the patients with osteoporosis. Therefore, a reasonable advice is to consider pharmacological treatment for osteoporosis in those UC patients who already present fragility fractures, which bring a high risk of subsequent fractures. Therapy has also to be considered in patients with a high risk of fracture even if it did not yet happen, and particularly when they had long periods of corticosteroid therapy or cumulative high dosages. In patients without fragility fractures or steroid treatment, a medical decision about treatment could be guided by the FRAX tool to determine the intervention threshold. Among drugs for osteoporosis treatment, the bisphosphonates are the most studied ones, with the best and longest evidence of efficacy and safety. Despite this, several questions are still open, such as the duration of treatment, the necessity to discontinue it, the indication of therapy in young patients, particularly in those without previous fractures. Further, it has to be mentioned that a long-term bisphosphonates use in primary osteoporosis has been associated with an increased incidence of dramatic side-effects, even if uncommon, like osteonecrosis of the jaw and atypical sub-trochanteric and diaphyseal femoral fractures. UC is a long-lasting disease and the majority of patients is relatively young. In this scenario primary prevention of fragility fracture is the best cost-effective strategy. Vitamin D supplementation, adequate calcium intake, suitable physical activity (when possible), removing of risk factors for osteoporosis like smoking, and avoiding falling are the best medical acts.

Keywords: Ulcerative colitis; Osteoporosis; Fragility fracture; Bone mineral density; Trabecular bone score; Hip structural analysis; Fracture assessment risk tool; Dual energy X-ray absorptiometry

Core tip: Diagnosis and treatment of osteoporosis in ulcerative colitis are discussed according to the latest evidence. Innovative applications of new programs derived from bone densitometry to evaluate bone quality and to predict fracture risk in patients affected by ulcerative colitis are described. Charts for ten years fracture risk may be utilized to refer patients to bone densitometry and/or to prescribe drugs against osteoporosis. Trabecular bone score and hip structural analysis may be considered to assess bone quality, that could be impaired by malabsorption and chronic inflammatory status. Advices for prevention and treatment of bone damage are given, also considering cost-effectiveness.