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Maintaing Bone Health in PSC

Maintaing Bone Health in PSC. M.Pioro MD Cleveland Clinic. No disclosures. Objectives. Normal bone What is osteoporosis? Risk factors for osteoporosis Increased osteoporosis in PSC How is osteoporosis diagnosed? What can be done about it? Calcium & vitamin D. TRABECULAR BONE.

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Maintaing Bone Health in PSC

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  1. Maintaing Bone Health in PSC M.Pioro MD Cleveland Clinic

  2. No disclosures

  3. Objectives • Normal bone • What is osteoporosis? • Risk factors for osteoporosis • Increased osteoporosis in PSC • How is osteoporosis diagnosed? • What can be done about it? • Calcium & vitamin D

  4. TRABECULAR BONE CORTICAL BONE

  5. Metabolic bone disease • Complication of PSC • Osteoporosis • Osteopenia

  6. Metabolic bone disease • Complication of PSC • Osteoporosis • Osteopenia

  7. Osteoporosis • Skeletal disorder characterized by • compromised bone strength predisposing to •  risk of fracture 2000 NIH consensus development conference

  8. Osteoporotic Fractures: • Vertebra 27% • Wrist 19% • Hip 14% • Pelvis 7% • Other 33% 54 yo 66 yo Burge et al. J Bone Miner Res 2007: 22: 465=475

  9. T12 Osteoporotic Fractures: • Vertebra 27% • Wrist 19% • Hip 14% • Pelvis 7% • Other 33% L1 L1 L4 L5 Burge et al. J Bone Miner Res 2007: 22: 465=475

  10. T12 Osteoporotic Fractures: • Vertebra 27% • Wrist 19% • Hip 14% • Pelvis 7% • Other 33% • Fragility fracture: any fracture that occurs from a standing height or less without major trauma (eg MVA) • Fractures of fingers, toes, face & skull are not considered to be fragility fractures • 10-20% risk of mortality within 1 yr of fragility fracture L1 L1 L4 L5 54 yo 66 yo Burge et al. J Bone Miner Res 2007: 22: 465=475

  11. Bone loss in women Women beginning at age 40, 0.5%/yr, then 1-2%/yr Women at menopause and for the next 5-8 yrs: 2-5%/yr National Osteoporosis Foundation Eastell et al. Hepatology 1991; 14: 296-300 http://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm

  12. Bone loss in women Women beginning at age 40, 0.5%/yr, then 1-2%/yr Women at menopause and for the next 5-8 yrs: 2-5%/yr Men 0.2-0.5%/yr National Osteoporosis Foundation Eastell et al. Hepatology 1991; 14: 296-300 http://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm

  13. Bone loss in women Women beginning at age 40, 0.5%/yr, then 1-2%/yr Women at menopause and for the next 5-8 yrs: 2-5%/yr Men 0.2-0.5%/yr Spinal cord injury ~1.5%/yr Spaceflight 1.5%/mth National Osteoporosis Foundation Eastell et al. Hepatology 1991; 14: 296-300 http://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm

  14. Bone loss in women Women beginning at age 40, 0.5%/yr, then 1-2%/yr Women at menopause and for the next 5-8 yrs: 2-5%/yr Women with PBC lose bone mass at 2x rate of age-matched controls Men 0.2-0.5%/yr Spinal cord injury ~1.5%/yr Spaceflight 1.5%/mth National Osteoporosis Foundation Eastell et al. Hepatology 1991; 14: 296-300 http://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm

  15. Risk factors for osteoporosis

  16. Osteoporosis in PSC • 237 PSC patients over 10 yrs • 15% osteoporosis • 41% osteopenia Angulo et al. Gastroenterology 2011; 140:180-188

  17. Osteoporosis in PSC • 237 PSC patients over 10 yrs • 15% osteoporosis • 41% osteopenia • Risk increased with • age • low BMI • chronic IBD Angulo et al. Gastroenterology 2011; 140:180-188

  18. Osteoporosis in PSC • 237 PSC patients over 10 yrs • 15% osteoporosis • 41% osteopenia • Risk increased with • age • low BMI • chronic IBD ¾ of patients with all 3 risk factors had osteoporosis Angulo et al. Gastroenterology 2011; 140:180-188

  19. Diagnosis: osteoporosis • Established by • BMD (bone mineral densitometry) • Hip or vertebral fracture in adulthood in the absence of major trauma

  20. Diagnosis: osteoporosis • Established by • BMD (bone mineral densitometry) • Hip or vertebral fracture in adulthood in the absence of major trauma

  21. very weak bone very strong bone 95% 68% Relative number of individuals at each level Number of standard deviations from average bone densitometry value T SCORE

  22. very weak bone very strong bone 95% 68% Relative number of individuals at each level Osteoporosis x -2.5 Number of standard deviations from average bone densitometry value T SCORE

  23. very weak bone very strong bone 95% 68% Osteopenia Relative number of individuals at each level Osteoporosis x -2.5 Number of standard deviations from average bone densitometry value T SCORE

  24. very weak bone very strong bone 95% 68% Severe osteoporosis T < -3.5 even without fractures T < -2.5 with fragility fracture Osteopenia Relative number of individuals at each level Osteoporosis x -2.5 Number of standard deviations from average bone densitometry value T SCORE

  25. Do not use T score in: • Premenopausal women • Men < 50 yrs • Children • Z < -2.0 “low BMD for age”, “below expected range for age” (not “osteoporosis” or “osteopenia”) • Z > -2.0 “within expected range for age” ”

  26. z Do not use T score in: • Premenopausal women • Men < 50 yrs • Children • Z < -2.0 “low BMD for age”, “below expected range for age” (not “osteoporosis” or “osteopenia”) • Z > -2.0 “within expected range for age” ”

  27. PSC: When should bone density test be done? • At diagnosis of PSC • Then every 2-4 years • History of fragility fracture • Before liver transplantation • Presence of cirrhosis • Steroid use > 3 months (prednisone > 7.5mg/d) On a case-by-case basis AASLD 2010 ACG 2014

  28. What can you do?

  29. Universal recommendations • Adequate Calcium / vitamin D • No smoking • Limit alcohol • Fall prevention • Weight bearing exercise/ balance training • Home modifications • Yearly height measurement

  30. What is normal height loss? Women & Men • Historical height loss (current ht compared to recalled ht as young adult) > 1.5 in (4 cm) • Prospective height loss (current ht compared to previous measured ht) > 0.8 in (2 cm) 83 yo www.ocso.org Higgs and AAOS 2001

  31. Recommended Daily Calcium intake • Young adults women & men • Adult women & men • 19-50 yrs • > 50 yrs • 1300mg/d • 1000mg/d • 1200mg/d National Academy of Sciences 1997

  32. Daily Calcium intake •  absorption with • Intestinal disease • Inflammatory bowel disease • Post bariatric surgery • Low stomach acid / antacids • (Nexium, Prilosec, etc)

  33. Dietary Calcium Okra

  34. ~300 mg Calcium: 8 oz glass milk 1 cup yogurt 2 oz cheese (4 cubes) ¼ cup grated cheese Goal: 1000-1200mg/d (4 dairy servings / day)

  35. Calcium supplements • Calcium carbonate • With food to absorb • 500 - 1500 mg tablets • 500 / 600mg elemental calcium • Calcium citrate • With/without food • Better with GI malabsorption • 950 - 1500 mg tablets • 200 / 315 / 500 mg elemental calcium

  36. Daily Calcium intake • Calcium carbonate • With food to absorb • 500 - 1500 mg tablets • 500 / 600mg elemental calcium • Calcium citrate • With/without food • Better with GI malabsorption • 950 - 1500 mg tablets • 200 / 315 / 500 mg elemental calcium READ THE LABEL 500MG elemental calcium

  37. Daily Calcium intake • Calcium carbonate • With food to absorb • 500 - 1500 mg tablets • 500 / 600mg elemental calcium • Calcium citrate • With/without food • Better with GI malabsorption • 950 - 1500 mg tablets • 200 / 315 / 500 mg elemental calcium READ THE LABEL 500MG elemental calcium Maximum 2500mg/d

  38. 70 mg 30 mg 111mg CAFFEINE: calciuric agent (calcium loss in urine)

  39. VITAMIN D

  40. VITAMIN D Need Vit D to absorb Ca

  41. 37 ° N

  42. 37 ° N

  43. 37 ° N SPF 8  vit D production by 95%

  44. 37 ° N SPF 8  vit D production by 95% Old skin = SPF 30

  45. Factors/Conditions associated with Vitamin D deficiency • Latitude • Sunscreen • Age • Dark Skin • Burns/scars • Chronic kidney disease • Malabsorption (Crohn’s) • Gastric bypass • Obesity • Liver disease (PSC) • Pregnancy/Lactation • Hyperparathyroidism • Osteomalacia • Chronic steroids • Anti-epileptics • HAART (HIV therapy)

  46. Factors/Conditions associated with Vitamin D deficiency • Latitude • Sunscreen • Age • Dark Skin • Burns/scars • Chronic kidney disease • Malabsorption (Crohn’s) • Gastric bypass • Obesity • Liver disease (PSC) • Pregnancy/Lactation • Hyperparathyroidism • Osteomalacia • Chronic steroids • Anti-epileptics • HAART (HIV therapy) Vitamin D deficiency: < 20 ng/ml

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