Osteoporosis in Patients With Inflammatory Bowel Disease

A 26-year-old woman presents with right lower-quadrant pain, nausea, and nonbloody diarrhea. She estimates that she has lost 15 pounds in the past 6 weeks. She had similar symptoms 11 months earlier; 9 months before this visit she was diagnosed with ileal Crohn’s disease on the basis of a colonoscopy and a small-bowel follow-through barium study. She was treated with prednisone 40 mg/day for 2 weeks and achieved complete remission. Prednisone was tapered by 5 mg/wk and then discontinued. She was on no medication intended to maintain remission. Her current symptoms started about 2 months before presentation and gradually have worsened. She has never smoked. She has been active on a league basketball team but in the past 4–6 weeks she has been unable to play because of her symptoms. Her menstrual periods have been regular. She took no medications other than acetaminophen for analgesia, and loperamide when she leaves her house. She has not previously had a bone fracture. On physical examination she looks tired but otherwise is well. She is muscular and appears well nourished. Her abdominal examination revealed a soft abdomen with tenderness in the right lower quadrant. Perineal inspection was unremarkable. Laboratory data included a serum hemoglobin level of 10.5 g/dL, mean corpuscular volume of 71fL, serum ferritin level of 8 mcg/L, serum albumin level of 31 g/L, and a C-reactive protein level of 44 mg/L. She is being treated with oral prednisone 40 mg/day with a plan to remain at this dose for 2 weeks and then taper by 5 mg/wk. She also has been started on azathioprine 100 mg/day with a plan to increase the dose as needed to maintain a corticosteroid-free remission. Should she fail to withdraw from corticosteroids or achieve remission, infliximab or surgery will be considered. The T scores at her spine are −1.8 and at her hip are −1.9 by dual-energy x-ray absorptiometry (DEXA) test.

Abbreviations used in this paper:  BMD, bone mineral density , DEXA, dual-energy x-ray absorptiometry , IBD, inflammatory bowel disease , RANK, receptor for activated nuclear factor kappa-B