Indian J Gastroenterol DOI 10.1007/s12664-014-0528-1
LETTER
Evaluating bone health in inflammatory bowel disease—A single tertiary care Veterans Hospital experience Jeffrey A. Gill & Susan Goldsmith & Ambuj Kumar
# Indian Society of Gastroenterology 2015
Dear Editor, At a time with increasingly important emphasis on preventative care, we wanted to share our experience with prevention of low bone density in veterans with inflammatory bowel disease (IBD). In 2003, the American Gastroenterological Association (AGA) made recommendations to screen IBD patients with at least one other risk factor for osteoporosis with a dual-energy X-ray absorptiometry (DXA) examination [1]. Despite this, and other literature supporting a relatively high incidence of osteoporosis in IBD patients, many gastroenterologists are still not adhering to these guidelines. We reviewed the charts of 172 IBD patients at the James A. Haley VA. Our study included all IBD clinic patients seen for follow up over 2 years, including 79 with Crohn’s disease, 92 with ulcerative colitis, and 1 with indeterminate colitis. Our primary outcome was the rate of adherence to AGA recommendations to order DXA scans for patients with IBD that have at least one strong risk factor for osteoporosis. Strong risk factors include age >50 years old, postmenopausal status, hypogonadism, steroid use for more than 3 months, and a history of a low-trauma fracture. Eighty-eight percent (152/ 172) of our patients had at least one strong risk factor for osteoporosis, and 26 % (39/152) had multiple strong risk J. A. Gill (*) : S. Goldsmith James A. Haley VA, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, USA e-mail: [email protected] A. Kumar University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612, USA
factors. Of the 152 patients with an indication for DXA scanning, only 30 % (46/152) had received one, which is similar to the 23 % of Khan et al. presented earlier this year in the American Journal of Gastroenterology among patients with Crohn’s disease in a veteran population [2]. Of our 46 patients scanned, nearly 85 % (39/46) had at least osteopenia and 21 % (10/46) had progressed to osteoporosis. Steroid use >3 months seemed to prompt providers to order a DXA scan with 18/33 having a DXA completed. Indeed this population needs it, as nearly 93 % of these patients with documented results (13/14) had a low bone density. Small bowel resection and age >50 were also impressive risk factors, associated with an incidence of osteopenia of 69 % and 73 %, respectfully. Full results of DXA scanning and documentation of results in relation to osteoporosis risk factors can be seen in Table 1. The incidence of osteoporosis and osteopenia in IBD patients has been estimated to range from 13 % to 50 %. Due to the higher incidence of low bone density, these patients have up to a 40 % greater incidence of fractures compared to the general population. This is due to many factors including the use of steroids to treat the disease, immobilization, a possible decrease in intestinal absorption of calcium and vitamin D, and a state of chronic inflammation [3]. Our study demonstrated that a low percentage of our IBD patients are getting screened for low bone density, and those which are screened are showing a high incidence of osteoporosis and osteopenia. We do not believe that these practices are isolated to our facility, but rather a broader problem which needs to be addressed. This was reinforced in a 2009 survey of AGA members showing that the guidelines for ordering DXA scans are not routinely followed [4]. Since our review was completed,
Indian J Gastroenterol Table 1
Risk factors correlation to DEXA testing, results, and documentation
Small bowel resection Age >50 Postmenopausal Steroid use >3 months Hypogonadism Fracture in past Smoking Low body mass index
% DEXA
% Documented
% Abnormal
% Osteopenia
% Osteoporosis
14/36 (38.9) 43/143 (30.1) 4/4 (100) 18/33 (54.5) 2/5 (40) 5/6 (83.3) 3/15 (20) 5/10 (50)
2/14 (14.3) 5/43 (11.6) 0/4 (0) 4/18 (22.2) 0/2 (0) 1/5 (20) 2/3 (66.7) 0/5 (0)
13/14 (92.9) 37/43 (86) 4/4 (100) 14/18 (77.8) 2/2 (100) 5/5 (100) 3/3 (100) 3/5 (60)
9/13 (69.2) 27/37 (73.0) 4/4 (100) 13/14 (92.9) 1/2 (50) 3/5 (60) 2/3 (66.7) 2/3 (66.7)
4/13 (30.8) 10/37 (27) 0/4 (0) 1/14 (7.1) 1/2 (50) 2/5 (40) 1/3 (33.3) 1/3 (33.3)
Values shown are n (%) DEXA dual-energy X-ray absorptiometry
we have created a template in the electronic medical record for our clinic notes to prompt the provider to address bone density in this population. We hope that this quality improvement will reduce the incidence of untreated osteoporosis and ultimately fractures in these patients. Acknowledgments This material is the result of a work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. Conflict of interest The contents of this publication do not represent the views of the Department of Veterans Affairs or the US Government. This study was not funded and the authors have no financial interests to declare.
References 1. American Gastroenterological Association medical position statement: guidelines on osteoporosis in gastrointestinal diseases. Gastroenterology. 2003;124:791–4. 2. Khan N, Abbas AM, Almukhtar RM, et al. Adherence and efficacy of screening for low bone mineral density among ulcerative colitis patients treated with corticosteroids. Am J Gastroenterol. 2014;109:572–8. 3. Katz S, Weinerman S. Osteoporosis and gastrointestinal disease. Gastroenterol Hepatol. 2010;6:506–17. 4. Wagnon JH, Leiman DA, Ayers GD, et al. Survey of gastroenterologists’ awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: are the guidelines being used and what are the barriers to their use? Inflamm Bowel Dis. 2009;15:1082–9.
LETTER
Evaluating bone health in inflammatory bowel disease—A single tertiary care Veterans Hospital experience Jeffrey A. Gill & Susan Goldsmith & Ambuj Kumar
# Indian Society of Gastroenterology 2015
Dear Editor, At a time with increasingly important emphasis on preventative care, we wanted to share our experience with prevention of low bone density in veterans with inflammatory bowel disease (IBD). In 2003, the American Gastroenterological Association (AGA) made recommendations to screen IBD patients with at least one other risk factor for osteoporosis with a dual-energy X-ray absorptiometry (DXA) examination [1]. Despite this, and other literature supporting a relatively high incidence of osteoporosis in IBD patients, many gastroenterologists are still not adhering to these guidelines. We reviewed the charts of 172 IBD patients at the James A. Haley VA. Our study included all IBD clinic patients seen for follow up over 2 years, including 79 with Crohn’s disease, 92 with ulcerative colitis, and 1 with indeterminate colitis. Our primary outcome was the rate of adherence to AGA recommendations to order DXA scans for patients with IBD that have at least one strong risk factor for osteoporosis. Strong risk factors include age >50 years old, postmenopausal status, hypogonadism, steroid use for more than 3 months, and a history of a low-trauma fracture. Eighty-eight percent (152/ 172) of our patients had at least one strong risk factor for osteoporosis, and 26 % (39/152) had multiple strong risk J. A. Gill (*) : S. Goldsmith James A. Haley VA, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, USA e-mail: [email protected] A. Kumar University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612, USA
factors. Of the 152 patients with an indication for DXA scanning, only 30 % (46/152) had received one, which is similar to the 23 % of Khan et al. presented earlier this year in the American Journal of Gastroenterology among patients with Crohn’s disease in a veteran population [2]. Of our 46 patients scanned, nearly 85 % (39/46) had at least osteopenia and 21 % (10/46) had progressed to osteoporosis. Steroid use >3 months seemed to prompt providers to order a DXA scan with 18/33 having a DXA completed. Indeed this population needs it, as nearly 93 % of these patients with documented results (13/14) had a low bone density. Small bowel resection and age >50 were also impressive risk factors, associated with an incidence of osteopenia of 69 % and 73 %, respectfully. Full results of DXA scanning and documentation of results in relation to osteoporosis risk factors can be seen in Table 1. The incidence of osteoporosis and osteopenia in IBD patients has been estimated to range from 13 % to 50 %. Due to the higher incidence of low bone density, these patients have up to a 40 % greater incidence of fractures compared to the general population. This is due to many factors including the use of steroids to treat the disease, immobilization, a possible decrease in intestinal absorption of calcium and vitamin D, and a state of chronic inflammation [3]. Our study demonstrated that a low percentage of our IBD patients are getting screened for low bone density, and those which are screened are showing a high incidence of osteoporosis and osteopenia. We do not believe that these practices are isolated to our facility, but rather a broader problem which needs to be addressed. This was reinforced in a 2009 survey of AGA members showing that the guidelines for ordering DXA scans are not routinely followed [4]. Since our review was completed,
Indian J Gastroenterol Table 1
Risk factors correlation to DEXA testing, results, and documentation
Small bowel resection Age >50 Postmenopausal Steroid use >3 months Hypogonadism Fracture in past Smoking Low body mass index
% DEXA
% Documented
% Abnormal
% Osteopenia
% Osteoporosis
14/36 (38.9) 43/143 (30.1) 4/4 (100) 18/33 (54.5) 2/5 (40) 5/6 (83.3) 3/15 (20) 5/10 (50)
2/14 (14.3) 5/43 (11.6) 0/4 (0) 4/18 (22.2) 0/2 (0) 1/5 (20) 2/3 (66.7) 0/5 (0)
13/14 (92.9) 37/43 (86) 4/4 (100) 14/18 (77.8) 2/2 (100) 5/5 (100) 3/3 (100) 3/5 (60)
9/13 (69.2) 27/37 (73.0) 4/4 (100) 13/14 (92.9) 1/2 (50) 3/5 (60) 2/3 (66.7) 2/3 (66.7)
4/13 (30.8) 10/37 (27) 0/4 (0) 1/14 (7.1) 1/2 (50) 2/5 (40) 1/3 (33.3) 1/3 (33.3)
Values shown are n (%) DEXA dual-energy X-ray absorptiometry
we have created a template in the electronic medical record for our clinic notes to prompt the provider to address bone density in this population. We hope that this quality improvement will reduce the incidence of untreated osteoporosis and ultimately fractures in these patients. Acknowledgments This material is the result of a work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. Conflict of interest The contents of this publication do not represent the views of the Department of Veterans Affairs or the US Government. This study was not funded and the authors have no financial interests to declare.
References 1. American Gastroenterological Association medical position statement: guidelines on osteoporosis in gastrointestinal diseases. Gastroenterology. 2003;124:791–4. 2. Khan N, Abbas AM, Almukhtar RM, et al. Adherence and efficacy of screening for low bone mineral density among ulcerative colitis patients treated with corticosteroids. Am J Gastroenterol. 2014;109:572–8. 3. Katz S, Weinerman S. Osteoporosis and gastrointestinal disease. Gastroenterol Hepatol. 2010;6:506–17. 4. Wagnon JH, Leiman DA, Ayers GD, et al. Survey of gastroenterologists’ awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: are the guidelines being used and what are the barriers to their use? Inflamm Bowel Dis. 2009;15:1082–9.
