The new BSG guidelines are designed to ensure that osteoporosis is not overlooked in patients with coeliac disease or IBD, explains Dr Brian Scott

During the past decade, there has been increasing awareness of the importance of osteoporosis, and the potential benefit from preventive and treatment strategies to reduce fractures.

In 1994 it was estimated that osteoporotic fractures in England and Wales cost £742 million per year.1 The predisposing factors have also become evident. It is now clear that certain patient groups are at increased risk of osteoporosis, and that it might be more cost-effective to target these groups rather than the general population.

It therefore behoves all clinicians involved in the management of patient groups at risk of osteoporosis Uo have an effective strategy for preventing, detecting and treating the condition.

Each patient group will have different degrees of risk, and in each group the risks will vary according to duration, severity, co-morbidity and treatment of the disease. It thus seems appropriate to produce separate guidelines for the different groups.

In gastroenterology, an increased risk of osteoporosis is seen mainly in those with malabsorption (usually coeliac disease), inflammatory bowel disease (IBD) (i.e. Crohn's disease and ulcerative colitis), alcohol abuse and chronic liver disease.

The new British Society of Gastroenterology (BSG) guidelines apply only to the management of osteoporosis in coeliac disease and IBD (see Tables 1 and 2 for summaries of the strategies). Guidelines for osteoporosis in the other conditions are in preparation.

Table 1: Summary of the strategy for prevention and treatment of osteoporosis in coeliac disease
general advice
  • Encourage patients to:
    • Adhere to strict gluten-free diet **
    • Take exercise ***
    • Stop smoking **
    • Avoid drinking excess alcohol **
  • Ensure adequate dietary calcium; add calcium supplement if needed to increase daily intake to 1500mg ***
  • Look out for vitamin D deficiency and treat if present
  • Determine BMD at diagnosis; if low, reinforce above advice

postmenopausal women

  • Determine BMD at the menopause or when patient is first seen
  • If patient is osteoporotic, recommend:
    • HRT, preferably by skin patch ***, or
    • Bisphosphonate orally ***, or
    • Calcitonin *

Men aged >55 years

  • Determine BMD
  • If patient is osteoporotic, recommend bisphosphonate or calcitonin **
All with fragility fracture
  • Determine BMD
  • If patient is osteoporotic, recommend HRT (if postmenopausal), bisphosphonate or calcitonin **
  • For those already taking HRT, consider adding bisphosphonate or calcitonin *
Duration of drug treatment
  • For patients on bisphosphonate or calcitonin, determine BMD annually
  • If BMD decreases by >4% per year in two consecutive years, change to other drug
  • If BMD does not fall, continue drug for at least 3 years, possibly long term ***
  • Restart drug if, after stopping, BMD falls by >4% annually
  • For those on HRT, check BMD after 10 years and continue HRT if steoporosis persists

†Osteoporosis is defined as BMD >2.5 SD below the mean for a young adult.***, ** and * indicate the level of evidence for the recommendation (see text). BMD = bone mineral density; HRT = hormone replacement therapy.

 

Table 2: Summary of the strategy for prevention and treatment of osteoporosis in inflammatory bowel disease

general advice
  • Encourage patients to:
    • Take exercise ***
    • Stop smoking **
    • Avoid drinking excess alcohol **
  • Ensure adequate dietary calcium; add calcium supplement if needed to increase daily intake to 1500mg ***
  • Look out for vitamin D deficiency and treat if present
postmenopausal women
  • Determine BMD at menopause or when patient is first seen
  • If patient is osteoporotic†, recommend:
    • HRT, preferably by skin patch ***, or
    • Bisphosphonate orally ***, or
    • Calcitonin **
Men aged >55 years
  • Determine BMD for all patients with Crohn's disease and patients with ulcerative colitis who have received systemic steroids
  • If patient is osteoporotic†, determine serum testosterone, and give replacement where low *
  • For those with normal testosterone, or BMD that does not improve on testosterone, recommend bisphosphonate or calcitonin **
All if systemic steroids are used
  • Give lowest dose for the shortest possible period
  • At the same time, give daily dose of 800 units vitamin D (e.g. two 'calcium and vitamin D' or two Calcichew D3 Forte tablets) **
  • Determine BMD and repeat each year in which steroid treatment is given
  • If T score is <–1.5* recommend bisphosphonate (in addition to vitamin D) ***

All with fragility fracture
  • Determine BMD
  • If patient is osteoporotic† recommend HRT (if postmenopausal), bisphosphonate or calcitonin **
  • For those already on HRT, consider adding bisphosphonate or calcitonin *

Duration of drug treatment

  • For patients on bisphosphonate or calcitonin, determine BMD annually
  • If BMD decreases by >4% per year in two consecutive years, change to another drug
  • If BMD does not fall, continue drug for at least 3 years, possibly long term ***
  • Restart drug if, after stopping, BMD falls by >4% annually
  • For those on HRT, check BMD after 10 years and continue HRT if steoporosis persists *
†Osteoporosis is defined as BMD >2.5 SD below the mean for a young adult. ***, ** and * indicate the level of evidence for the recommendation (see text). BMD = bone mineral density; HRT = hormone replacement therapy.

Although written primarily for gastroenterologists, the guidelines are applicable to family doctors if they have access to bone mineral density measurements. Dual-energy X-ray absorptiometry (DEXA) scanning is now preferred, but this is not available in all hospitals. Heel ultrasound scanning is thought to be a reasonable alternative, and has the advantages of being portable and much cheaper.

A thorough literature search in 1998 produced 81 appropriate references on which to base the guidelines.

The best evidence was for the prevalence of osteoporosis in coeliac disease and IBD, and for the various risk factors such as non-adherence to a gluten-free diet, low body mass index, menopausal age, low calcium intake, and steroid use.

Almost 50% of coeliac patients have been shown to have osteoporosis and there is convincing evidence that a gluten-free diet improves bone mineral density.

IBD is much more heterogeneous and generalisation is more difficult. However, one can probably expect about a third of Crohn's disease patients and rather fewer ulcerative colitis patients to have osteoporosis, which is related to both steroid use and low body mass index.

There was less evidence for the effectiveness of drug treatments in the prevention and treatment of osteoporosis in coeliac disease and IBD in particular, and therefore reliance had to be placed on the results of studies in other patient populations.

The final guidelines were tabulated and each recommendation was graded *, ** or *** according to the level of evidence:

Level *** indicates evidence from well-conducted randomised controlled trials
Level ** indicates evidence from prospective non-randomised controlled trials, good observational studies or retrospective and cross-sectional studies
Level * indicates evidence from expert opinion or from extrapolation from level ** evidence.

For coeliac disease, of 15 prevention or treatment recommendations, six were level ***, five were level ** and two were level *.

For IBD, of 18 prevention or treatment recommendations, seven were level ***, five were level ** and three were level *.

Although the guidelines are based on published evidence as far as possible, they are of necessity arbitrary to some extent, because of the many gaps in our knowledge. Clearly, alternative strategies might be just as valid, and these guidelines are offered as a basis for rational management of two common gastrointestinal disorders. It is anticipated that the guidelines will be fine-tuned with experience of applying them and as the results of further studies emerge.

A strategy for osteoporosis in gastroenterology was produced by the authors for the European Journal of Gastroenterology and Hepatology.3 Before publication in 1998 it went through a thorough peer review process involving four experts. Many changes were made as a result of their helpful comments.

The published paper then became the basis of these guidelines for the BSG. The format was changed considerably and there was further peer review by all members of the Clinical Services & Standards Committee of the BSG and the Council of the BSG. Further changes were required by the editorial committee of Gut, the journal responsible for publishing the guidelines.2

The management of coeliac disease and particularly IBD already requires much attention to detail, and it is therefore easy to overlook the problem of osteoporosis in these patients, especially when it may not present until several decades later. Guidelines can prompt and simplify the management of this oft-forgotten aspect of other diseases.

Furthermore, patients are now much more knowledgeable about their diseases and are aware of the problem of osteoporosis through widespread publicity in newspapers and popular magazines. Thus they often expect their doctor also to be alert to the problem, and confidence in their doctor can accordingly be either reinforced or lost.

The authors of the guidelines are practising clinicians and bring together expertise in gastro“nterology, rheumatology and endocrinology. They are aware of the pressures on busy clinicians and have tried to simplify the strategy as far as possible.

The management of osteoporosis in coeliac disease and IBD is not straightforward, and it is difficult, even for the authors of the guidelines, to remember what to do in particular circumstances. Having the guidelines to hand in the clinic will ensure that an appropriate course of action is followed.

We have had to balance strict interpretation of the evidence and ease of application of the guidelines. We realise that there is little value in producing guidelines if they are too difficult to apply.

This is probably most important for patients with IBD disease on long-term low-dose steroids or repeated courses of high-dose steroids. While accepting that there is no evidence about the risk of osteoporosis from long-term use of prednisolone in a dose no higher than 7.5 mg, to simplify management in this group we have recommended bone mineral density measurement in every year in which steroids at any dose are given.

Osteoporosis is common in coeliac disease and IBD.
There is a correlation with low body mass index and use of steroids.
In coeliac disease, bone mineral density improves with a gluten-free diet.
General advice on diet, exercise, smoking and alcohol should be given to all patients.
Bone mineral density measurement at appropriate times can detect osteoporosis and allow prompt treatment.
Bone mineral density measurements in patients on steroids can detect those at risk of osteo- porosis, allowing prophylactic bisphosphonate therapy.
Ready reference to guidelines is necessary for optimal management.

  1. Department of Health. Report of the Advisory Group on Osteoporosis. London: HMSO, 1994.
  2. Scott EM, Gaywood I, Scott BB. Guidelines for osteoporosis in coeliac disease and inflammatory bowel disease. Gut 2000; 46 (Suppl 1): 11-18.
  3. Scott EM, Scott BB. A strategy for osteoporosis in gastroenterology. Eur J Gastroenterol Hepatol 1998; 10: 689-98.

Tables 1 and 2 are adapted from the British Society of Gastroenterology Guidelines for Osteoporosis in Coeliac Disease and Inflammatory Bowel Disease.

For a printed copy of the full guidelines, contact Chris Romaya at the British Society of Gastroenterology, 3 St Andrews Place, Regent's Park, London NW1 4LB (tel 020 7935 2815; fax 020 7487 3734; email bsg@mailbox.ulcc.ac.uk). The guidelines can also be downloaded from the BSG website at http://www.bsg.org.uk/guidelines.html

Guidelines in Practice, May 2000, Volume 3
© 2000 MGP Ltd
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