WILL I BE OFFERED TREATMENT?

The results from a DEXA scan are used to work out a bone density ‘score’ by comparing your bone density to that of the general population. Treatment recommendations then depend on this score and on your other risk factors, for example, whether you have used steroids or have had fractures in the past.

WHAT TREATMENTS ARE THERE?

Treatments for low bone density and osteoporosis are aimed at strengthening existing bones, preventing further bone loss and reducing the risk of fractures.

• Calcium and vitamin D – ensuring that you are taking enough of these is an important first step, and supplements may be recommended. Supplementation is offered for people found to have low levels or who have been undergoing corticosteroid treatment. If you have difficulty absorbing nutrients, as sometimes happens with Crohn’s Disease, you may be prescribed additional high dose vitamin D supplements. Research suggests that people with IBD who have low levels of vitamin D are more likely to be hospitalised or have surgery related to IBD, compared to those with higher levels of vitamin D. It is, however, unclear whether low levels are a consequence of more severe IBD.

• Bisphosphonate drugs - for example, alendronate, ibandronate and risedronate sodium, have been used for some years in the treatment of osteoporosis. They work by slowing down cells which break down bone (osteoclasts) and allow the bone building cells (osteoblasts) to work more effectively. Research shows bisphosphonates are effective and well tolerated in people with IBD, and can be used to prevent and treat bone loss linked to steroids. Bisphosphonates, which can be taken daily, weekly, monthly or even once every three months depending on the type prescribed, usually come in tablet form. Some bisphosphonates, such as ibandronate, can be given as an intravenous (into a vein) injection. If you are prescribed oral (by mouth) bisphosphonates, it is important to take the tablets exactly as directed. This may be, for example, upright while sitting or standing, with plenty of water, to reduce the risk of irritating the lining of the oesophagus (gullet). Since bisphosphonates are poorly absorbed they must be taken on an empty stomach – the patient information leaflet that comes with your tablets will tell you exactly how long you should wait before eating. Questions exist around duration of bisphosphonates, and there have been side effects reported as a result of the treatment including a rare dental disease (osteonecrosis of the jaw). Guidance suggests that all patients receiving intravenous bisphosphonates should have a dental check-up before starting treatment. Bisphosphonates are not recommended for women who are pregnant, or might become pregnant in the future, or who are breastfeeding. Pregnant women need to weigh up with doctors their individual benefits for continuing treatment against possible risks to the pregnancy. Speak to your doctor or IBD team if you are taking bisphosphonates and you are thinking of starting a family.

• Taking extra oestrogen (also known as hormone replacement therapy or HRT) - particularly in post-menopausal women, can help reduce bone loss. However, HRT is less commonly used for osteoporosis because research found a small but significantly increased risk of breast cancer, blood clots (venous thromboembolism), stroke and ovarian cancer. If you are concerned, it may be worth discussing this with your doctor or our IBD team. For some men with osteoporosis, testosterone replacement may be effective. This may be given as injections, implants, daily patches or tablets.

• Other drugs for osteoporosis - your doctor may prescribe these. Raloxifene belongs to a group of drugs called selective estrogen receptor modulators (SERMs) that mimic the action of oestrogen on certain organs, (such as bone) and block it in others (such as breast tissue). This overcomes the risk of breast cancer that has been observed with HRT. Strontium ranelate (which has the dual action of increasing new bone production and reducing old bone breakdown) is reserved for people in whom other osteoporosis drugs do not work.

• Chinese herbal medicines - can be used to treat osteoporosis, but a recent analysis of multiple studies concluded that the beneficial effects were uncertain and more research was needed. The use of complementary or alternative medicines, nutritional supplements, herbal and homeopathic remedies should always be discussed with your health care team. Avascular necrosis of the hip is a rare but serious condition that often needs surgical treatment. If you develop hip pain during steroid therapy, report it to your doctor or our IBD team. With effective treatment, improved bone density can usually be confirmed with follow up DEXA scans. However, as bone strengthening is a gradual process, it will not show up immediately.

HOW CAN BONE LOSS BE PREVENTED?

Osteoporosis is far better prevented than treated. If you are concerned that you may develop weak bones, the following suggestions may help:

• If you can, take regular weight-bearing exercise, such as brisk walking, jogging, dancing, aerobics, or active team sports. Gardening and housework, even just using the stairs whenever possible, can also be useful, as any weight-bearing activity stimulates bone formation. Outdoor exercise is especially valuable as this will increase your exposure to sunlight and boost your vitamin D production. If in doubt, ask your doctor for guidance on exercise.

• Avoid smoking and reduce alcohol intake.

• Ensure you have adequate calcium and vitamin D, which are important for bone strengthening. The daily recommended intake of Vitamin D is 800 units. Guidelines for people with IBD recommend a daily intake of 1000 mg of calcium for people under 55, and 1200mg for over 55s.

• If you are not getting enough calcium from your food, perhaps because you are avoiding dairy products, you may need calcium supplements. It may be worth discussing this with your doctor or our IBD Team as they may be able to prescribe combined calcium and vitamin D supplements. Some people overestimate their dairy sensitivity, and avoid milk and milk products unnecessarily. Recent studies suggest calcium supplements can increase the risk of heart disease, but other research has not confirmed this finding.

• If you are taking steroids, talk about prevention of bone loss with your doctor or our IBD team. Calcium and vitamin D supplements are often used for those on steroid treatment. You may also be given bisphosphonates while on steroids. Some of the newer steroids, such as budesonide, may be less harmful to the bones as they usually only affect the bowel, and so may be helpful for people with some forms of Crohn’s Disease. For people with UC, newer forms of budesonide, such as multimatrix or ‘MMX’ allows the drug to be released throughout the colon. Prolonged use of steroids can sometimes be avoided by taking immunosuppressants such as azathioprine and biological drugs, for example, infliximab. New research suggests infliximab may also have the additional benefit of improving bone density in people with Crohn’s Disease. See our medication section.

• If you are a woman with IBD who has reached the menopause and is at risk of thinning bones, it may be best to speak to your doctor or our IBD team about bone loss, even if you are not on steroid treatment.

• Continuing to take your IBD medications may reduce the risk of osteoporosis by minimising the amount of ongoing inflammation in the gut. Speak to our IBD team to weigh up the risks and benefits that taking steroids may have on your bones.

By being aware of the risk of bone loss, you may be able to change your diet or lifestyle to help prevent it. Also, appropriate treatment can now significantly reduce the risk of bone disease.

SOURCES OF CALCIUM

Dairy sources:

• Milk (skimmed milk contains slightly more calcium than whole milk)

• Hard and soft cheeses

• Yogurt, fromage frais, dairy ice cream

Non-dairy sources:

• Fortified soya milk

• Tofu

• Green leafy vegetables such as broccoli and cabbage

• Fish with edible bones, such as pilchards and sardines

• Nuts Sources of Vitamin D

• Exposure to sunlight

• Oily fish such as salmon and sardines

• Eggs

• Fortified fat spreads and breakfast cereals

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References