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Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines) Athos Bousvaros MD, MPH Boston Children’s Hospital.

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Presentation on theme: "Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines) Athos Bousvaros MD, MPH Boston Children’s Hospital."— Presentation transcript:

1 Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines) Athos Bousvaros MD, MPH Boston Children’s Hospital

2 Disclosures Consulting: Milennium, Dyax, Cubist, Nutricia Research support: Prometheus, Merck With gratitude to Helen Pappa, Francisco Sylvester, and the NASPGHAN Skeletal Health working guideline. JPGN 2011

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4 Bone mass is acquired in childhood and adolescence

5 Causes of low bone density in IBD patients Inflammation Low muscle mass Glucocorticoids Delayed puberty Hypovitaminosis D Delayed growth Protein-calorie malnutrition GENETICS

6 How to approach the issue of low bone mineral density in pediatric IBD Ignore it Treat everybody Screen and treat those who need to be treated

7 Which recommendations to follow? THESE – Screen and treat Journal Pediatric GI and Nutrition 2011; 11-25

8 Who to get DEXA on? – Growth failure Height Z score <-2.0 SD BMI <2.0 SD – Primary or secondary amenorrhea – Severe inflammatory disease, esp. hypoalbuminemia – > 6 months of steroid therapy – Clinically significant fractures

9 What kind of DEXA to get Children under 14 years – Total body and spine Children 14 and over – Hip and spine Cost under $150* *healthcarebluebook.com

10 Who and when to get a 25 hydroxy vitamin D level on? Everyone – African American children at higher risk* Once a year, in the winter (cost-$30) If low (<32 ng/ml), treat: – 50,000 units once a week for 10 weeks – Ensure adequate calcium intake during this period *Middleton, JPGN 2013; 57:587

11 Why screen and treat? Not everyone needs to be treated % of children with IBD will have a NORMAL BMD Z score Low bone mineral density may change your therapeutic decisions – Additional data in patient decision making – Use steroid sparing agents (e.g. infliximab) – Implement nutritional therapy faster – More rigorous diet/exercise program – Referral to endocrinologist TREATDon’t treat

12 Why screen and treat? Adherence, adherence, adherence!!!! – Approximately 70% of medication doses (ASA and thiopurine) are taken by children – Approximately 25% of adolescents take over 80% of their prescribed ASA doses – Approximately 15% of adolescents take their prescribed thiopurine doses. Calcium and vitamin D = 2-3 extra tabs per day (cost $40/year) Leleiko IBD Journal 2013;19:832

13 Summary: Screen and treat Prevention of osteoporosis is important Not everyone needs to be screened – Focus on the high risk groups Not everyone needs to be treated – Treat those with BMD Z score <-1.0 Treat suboptimal BMD like an extraintestinal manifestation of IBD – Control inflammation, optimize nutrition – Follow up, and monitor adherence


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