Osteoporosis

Osteoporosis is a condition that makes your bones weaker and more likely to break.¹ There is a link between having inflammatory bowel disease (IBD) and a greater risk of osteoporosis. Several studies have shown that about 15% of patients with Crohn’s disease and ulcerative colitis have osteoporosis.²

Why is inflammatory bowel disease linked with osteoporosis?

There are many possible explanations for the link between IBD and osteoporosis.¹ In a healthy individual, bone is constantly breaking down and being rebuilt. This is called bone metabolism. These activities are in balance, so that your bones stay strong. IBD is an inflammatory condition. Inflammation in the body causes many changes, including changes in bone metabolism. Osteoclasts—the “bone chewing” cells that break down bone—may become overactive. The osteoblasts—the “bone building” cells—are not able to keep up. The result is that your bones get weaker.¹

Changes in diet or problems with absorbing nutrients can contribute to weaker bones.¹ Calcium and vitamin D are 2 important nutrients for bone health. People with IBD typically eat fewer foods that are high in calcium and vitamin D. Crohn’s disease in the small intestine could cause problems with absorbing these nutrients. Studies have shown that more than 70% of people with Crohn’s disease have low vitamin D levels. For this reason, your health care provider may suggest having your vitamin D levels checked regularly.¹

Corticosteroids are often used to treat IBD.¹ Corticosteroids are strongly linked with osteoporosis. These medications block the osteoblasts and increase the activity of osteoclasts. The result is rapid bone loss at a young age. Between 25% and 50% of people using long-term corticosteroids will have a bone fracture.³

Finally, both osteoporosis and IBD have several overlapping risk factors. For example, many people with active IBD have low body weight. Being underweight is also a risk factor for osteoporosis. Smoking increases the risk of Crohn’s disease and fractures.^1,4 Low levels of physical activity have been linked with IBD, yet weight-bearing exercises protect against osteoporosis.^1,5

What are symptoms of osteoporosis?

Osteoporosis does not cause any symptoms until you have a fracture.¹ For this reason, it is important to talk with your health care provider about being screened for osteoporosis.

How is osteoporosis evaluated?

The main test used to diagnose osteoporosis is dual-energy x-ray absorptiometry (DXA).¹ This test measures bone mineral density (BMD). BMD is a measure of how much calcium and other minerals are in your bones.⁶ The results indicate whether you have osteopenia (early bone loss) or osteoporosis.

The screening recommendations for people with IBD are similar to the recommendations for a general population. Your BMD should be tested if you:^1,7

• Have had a fracture as an adult.
• Used corticosteroids for more than 3 months.
• Used corticosteroids repeatedly over time.
• Are postmenopausal (for women) or older than 50 years (for men).

The results of a BMD test are given as a T-score or Z-score.⁷ T-score compares your bone density with healthy young person of the same sex.⁶ It is used for postmenopausal women and men age 50 years and older. If your T-score -1.0 to -2.5, your provider may recommend having another DXA in 2 years.¹ If your T-score is -2.5 or less, your health care provider may recommend starting an osteoporosis medication.

Z-score is used for premenopausal women, men younger than 50 years, and children. It is a comparison of your bone density with the bone density in a healthy population of the same age, sex, and ethnicity.

Vertebral imaging is another test used to evaluate bone health. Vertebral imaging is done to check for fractures in the vertebrae. Most of the time, these fractures do not cause any symptoms. However, having a vertebral fracture increases the risk of having another fracture. Vertebral imaging is recommended for people who have used corticosteroids recently or for long-term treatment.⁷

How is osteoporosis prevented and treated?

Several lifestyle factors contribute to osteoporosis or fractures. These include:⁷

• Smoking.
• Inadequate physical activity and weight-bearing exercise.
• Drinking more than 3 alcoholic drinks per day.

Making changes to these factors may help to prevent osteoporosis.

The National Osteoporosis Foundation recommends that all postmenopausal women and men older than 50 years get adequate calcium and vitamin D through diet and supplementation (Table).⁷

Table. Calcium and Vitamin D: Recommendations for Bone Health

Source: Cosman F, et al. Osteoporos Int. 2014;25:2359-2381.

Several different kinds of osteoporosis medications are available.⁷ Some are taken by mouth, others are given by injection. Some are taken daily and others are taken less frequently. You can work with your health care provider to find a medication that suits your needs.

What are complications of osteoporosis?

The main complication of osteoporosis is fracture. One study found when people with IBD were compared with controls, the people with bowel disease were 40% more like to have a major fracture.¹

Osteoporosis-related fractures have serious consequences. Having one fracture doubles the risk of having another fracture for women. For men, a second fracture is 3.5 times more likely.⁸ Fracture is linked to an increase the risk of death and disability. Between 16% and 23% of women die within a year of having a hip fracture. Among men, 28% to 51% die in the year after a hip fracture. About half of patients are permanently immobilized after a hip fracture.¹