TNF-alpha inhibitors do not limit osteoporosis in Crohn's disease

Reuters Health Information: TNF-alpha inhibitors do not limit osteoporosis in Crohn's disease

TNF-alpha inhibitors do not limit osteoporosis in Crohn's disease

Last Updated: 2018-01-02

By Will Boggs MD

NEW YORK (Reuters Health) - Patients with Crohn's disease (CD) develop similar rates of osteoporosis, osteopenia, and normal bone density whether or not they are treated with TNF-alpha inhibitors, researchers report.

Numerous studies have documented a high incidence of vitamin D deficiency, osteoporosis, and bone fractures in CD patients, and various inflammatory cytokines, including TNF-alpha, have been linked to increased bone resorption. Few studies, however, have evaluated the impact of anti-TNF medications on osteoporosis and fracture risk in CD patients.

Dr. Shahrad Hakimian from UMass Memorial Medical Center, Worcester, Massachusetts, and colleagues added to the evidence base by reviewing data on 464 patients with CD. The findings were published online December 13 in the Scandinavian Journal of Gastroenterology.

Average vitamin D levels were similar, albeit low, in the TNF treatment group (19.9 ng/mL) and in the TNF-treatment-naive group (20.9 ng/mL). The two groups also did not differ in their rates of vitamin D deficiency, insufficiency, and normal vitamin D levels.

Bone density scans in 168 patients showed similar rates of osteoporosis, osteopenia, and normal bone density between the TNF treatment group (100 patients) and the treatment-naive group (68).

Osteoporosis rates for patients under age 60 were higher for those using TNF-alpha inhibitors than for nonusers (15.4% vs. 3.6%); osteoporosis rates among patients 60 or older were lower with TNF treatment (18.2%) than with nonuse (30.0%).

Few patients (9% of the TNF group and 16% of the treatment-naive group) had any type of fracture. Among the patients who did have fractures, their average age at fracture was 47 years in the TNF group versus 61 years in the treatment-naive group.

"Further large prospective studies comparing bone density before and after initiation of anti-TNF medications may potentially be helpful in addressing some of the confounders present in the current study," the researchers conclude. "It is important to recognize and treat osteoporosis and vitamin D deficiency in this patient population to minimize this risk."

Dr. Francisco Augusto Sylvester from University of North Carolina, Chapel Hill, who recently reviewed the effects of inflammatory bowel disease on bone, told Reuters Health by email, "The study is provocative, as it suggests that anti-TNF agents are associated with worse bone health in adults with Crohn's disease. However, I don't think that this study definitively shows that the anti-TNF agents per se are responsible for worse bone mass in patients with Crohn's disease. Their main result may be biased due to confounding by association."

"In this study, patients with Crohn's disease with more severe disease received anti-TNF agents (as evidenced by more frequent complicated disease and admissions to hospital)," he explained. "Therefore, it is quite possible that the more severe Crohn's disease is responsible for worse bone health and not the anti-TNF agent. History of corticosteroid use was not tracked, which could have also influenced results. In addition, clinicians may have obtained (none density) scans in patients in whom they were concerned about osteoporosis, which could have biased results as well."

He added, "In children, prospective studies have shown a significant improvement in bone health on anti-TNF agents."

"Therefore, I agree with the authors that properly designed prospective studies are needed to settle the question about the effects of anti-TNF therapy on bone in adults," Dr. Sylvester concluded. "Until these results are available, we should not change practice in the use of anti-TNF agents based on low bone mineral density (BMD) T scores."

"A note of caution is the terminology osteoporosis/osteopenia and associated BMD T scores," he added. "These definitions are appropriate for postmenopausal women, and in menopause there is a correlation between the risk of fractures and BMD T scores. However, this correlation has not been validated in patients with Crohn's disease. Therefore, alternative terminology such as low BMD T scores for age should be used instead."

Dr. Hakimian did not respond to a request for comment.


Scand J Gastroenterol 2017.

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