Letter to the Editor Open Access
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 21, 2021; 27(27): 4481-4483
Published online Jul 21, 2021. doi: 10.3748/wjg.v27.i27.4481
Is there higher percentage of undetected osteopenia and osteoporosis among patients with ulcerative colitis in Saudi Arabia?
Ivna Olic Akrapovic, Intensive Care Unit of the Department of Internal Medicine, University Hospital Centre Split, Split 21000, Croatia
Mislav Radic, Division of Rheumatology and Clinical Immunology, Centre of Excellence for Systemic Sclerosis Ministry of Health Republic of Croatia, University Hospital Centre Split, Split 21000, Croatia
Mislav Radic, Ante Tonkic, School of Medicine, University of Split, Split 21000, Croatia
Ante Tonkic, Department of Gastroenterology and Hepatology, University Hospital Centre Split, Split 21000, Croatia
ORCID number: Ivna Olic Akrapovic (Not Applicable); Mislav Radic (0000-0003-0350-6800); Ante Tonkic (0000-0002-3217-6890).
Author contributions: Akrapovic Olic I and Radic M designed research; Akrapovic Olic I performed research; Akrapovic Olic I and Radic M analyzed data; Akrapovic Olic I wrote the letter; Radic M and Tonkic A revised the letter.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mislav Radic, PhD, Assistant Professor, Division of Rheumatology and Clinical Immunology, Centre of Excellence for Systemic Sclerosis Ministry of Health Republic of Croatia, University Hospital Centre Split, Soltanska 1, Split 21000, Croatia. mislavradic@gmail.com
Received: January 17, 2021
Peer-review started: January 17, 2021
First decision: February 23, 2021
Revised: March 29, 2021
Accepted: June 25, 2021
Article in press: June 25, 2021
Published online: July 21, 2021


Detection of prevalence and development of osteopenia or osteoporosis in patients with inflammatory bowel disease using only bone mineral density could be inappropriate to detect all individuals at risk for osteoporosis. Numerous patients could remain undetected by using only bone mineral density as a screening method, especially in patients with ulcerative colitis. Therefore, trabecular bone score should be used as a complementary method.

Key Words: Inflammatory bowel disease, Osteoporosis, Bone mineral density, Trabecular bone score

Core Tip: Lower body mass index is a predictor of osteoporosis in patients with inflammatory bowel disease however, fracture risk can be increased desite normal bone mineral density. Therefore, use of trabecular bone score would ensure recruitment of individuals with normal bone mineral density at increased risk of fractures in trials.


We read with a great interest the study by Ewid et al[1], that evaluated the connection between inflammatory bowel disease (IBD) and bone mineral density (BMD) in a sample of adult Saudi patients with IBD from a single center.

One important finding of this study was that Crohn’s disease (CD) patients are at a higher risk of developing both osteoporosis and osteopenia than ulcerative colitis (UC) patients, even though the study included more patients with severe clinical disease activity and endoscopic activity in the UC group than in the CD group (25% vs 5%, respectively). In spite of disease severity, 78% of UC patients had normal BMD vs 44% of CD patients. Fracture risk can be increased despite normal BMD. Maldonado et al[2] suggested that current screening does not include all IBD patients at increased risk of fractures. We propose using trabecular bone score (TBS) as a complementary tool; as it discriminates patients at higher risk of fractures better than BMD[3].

According to demographic characteristics in the study, mesalamine use was significantly higher in the UC compared to CD group (81% vs 10%, respectively). Due to the sample size of UC group an analysis of BMD according to mesalamine use probably could not have been performed nevertheless, the analysis would be highly informative. Hence, we postulate a question: could mesalamine use have contributed to lower risk of developing osteoporosis in UC compared to the CD cohort?

Krajcovicova et al[4] observed no significant difference in the prevalence of low BMD in groups of patients with UC and CD. They observed that corticosteroid therapy and menopause had significant negative effects, whereas combined treatment with an anti-tumor necrosis factor (TNF) α agent and azathioprine had a significant positive effect on Δ BMD at the lumbar spine (BMDL) per year[4].

The study also showed that low BMI is a risk factor for reduced BMD. According to Fawzy et al[5] and Steinschneider et al[6], increased BMD commonly reported in overweight women may be a result of soft tissue interference, further supporting addition of TBS as a screening method for osteoporosis in research and clinical practice.

An unexpected finding in this study is the lack of correlation between steroid use and BMD. Paggiosi et al[7] demonstrated that TBS alone and BMDL in combination with TBS, but not BMDL alone were able to discriminate between glucocorticoid-treated and glucocorticoid-naïve women. In the study by Gulyás et al[8] TNF-α inhibition slowed down generalized bone loss in rheumatoid arthritis and ankylosing spondylitis. Effect of anti TNF therapy on bone metabolism was not confirmed by Ewid et al[1] hence, the effect is questionable in IBD.

Addition of TBS would enable inclusion of individuals with normal BMD at increased fracture risk. In conclusion, by including both screening methods osteoporotic fracture risk in UC vs CD cohort could be assessed more accurately.


Manuscript source: Unsolicited manuscript

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Croatia

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P-Reviewer: Huan C, Kamimura K, Takagi T, Wakao H S-Editor: Liu M L-Editor: A P-Editor: Wang LL

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