Ernæringsmangler og IBD. Jørgen Jahnsen

Transkript

1 Ernæringsmangler og IBD Jørgen Jahnsen

2 Inflammatoriske tarmsykdommer Crohns sykdom Ulcerøs kolitt IBD

3 Lokalisasjon Endoskopi Histologi Crohns sykdom Ulcerøs kolitt

4 Komplikasjoner ved IBD Crohns sykdom Fistler Perianal sykdom Strikturer Blødning Vekttap/malnutrisjon Vekst forstyrrelser Anemi Artralgier/arthritt Uveitt Erythema nodosum Metabolsk beinsykdom Ulcerøs kolitt Blødning Anemi Vekttap/malnutrisjon Vekst forstyrrelser Artralgier/arthritt Uveitt Erythema nodosum PSC

5 Komplikasjoner ved IBD Crohns sykdom Fistler Perianal sykdom Strikturer Blødning Vekttap/malnutrisjon Vekst forstyrrelser Anemi Artralgier/arthritt Uveitt Erythema nodosum Metabolsk beinsykdom Ulcerøs kolitt Blødning Anemi Vekttap/malnutrisjon Vekst forstyrrelser Artralgier/arthritt Uveitt Erythema nodosum PSC

6 Nutritional deficiencies in patients with IBD Filippi J, et al.. Inflamm Bowel Dis 2006; 12: Vagianos K et al. JPEN J Parenter Enteral Nutr 2007; 31:

7 Jernmangel hos IBD pasienter Den mest vanlige mangeltilstanden 36-90% Lavt inntak Hemmet opptak fra tarmen Crohns sykdom (L4) Inflammasjonen Kontinuerlig blodtap Synlig (ulcerøs kolitt) Usynlig (Crohns sykdom) Lomer MC, Br J Nutr Semrin G, Inflamm Bowel Dis 2006 Kulnigg S, APT 2006

8 The prevalence of anemia and iron deficiency in IBD outpatients in Scandinavia Overall prevalence: 19% (95% CI: 16-23%) Crohns disease > ulcerative colitis (p=0.01) Aetiology of anaemia Iron deficiency (20%) Chronic inflammation (12%) Both Iron deficiency and chronic inflammation (68%) Folate acid or B12 deficiency (<5%) Iron deficiency: 35 % (95% CI: 31-40%) Bager P et al. Scand J Gastroenterol 2011 Mar;46(3):304-9.

9 Anemia in IBD - pathophysiological mechanisms Weiss G, Gasche C Haematologica Feb;95(2):175-8.

10 IBD-associated anemia and iron deficiency after intravenous iron sucrose and erythropoietin treatment Objective Evaluate the frequency and timing of anemia and ID recurrence after a successful treatment cycle Methods Medical records of patients who received iv iron sucrose ± EPO within one of three prospective trials Gasche et al, Ann Intern Med 1997, Digestion 1999, and Am J Gastroenterol 2001 studied for a 5-year follow-up period Risk for recurrence of anemia and ID (ferritin < 30 μg/l) was evaluated by Kaplan Meier analysis using the logrank test Kulnigg S et al. Am J Gastroenterol 2009 Jun;104(6):

11 Characteristics of patients sorted by iron dose before + after iron replacement therapy More iron = higher hemoglobin and iron parameters Kulnigg S et al. Am J Gastroenterol 2009 Jun;104(6):

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13 Iron dosage Hemoglobin < normal Ferritin < 30µg/L TfS < 16% Iron re-treatment

14 Post-treatment ferritin level Hemoglobin < normal Ferritin < 30µg/L TfS < 16% Iron re-treatment

15 Conclusions The higher the initial iron dose, the better was the initial treatment outcome IBD-associated iron deficiency and anemia recurs fast Appropriate dosing is not well established Recurrence of anemia did not relate to iron dose or post-treatment ferritin

16 Conclusions Post-treatment ferritin levels predict recurrence of iron deficiency but not anemia Ferritin level of at least 400 μg/l after iv iron treatment (with an upper safety limit of 800 μg/l to avoid iron overload) Iron (and/or EPO) maintenance therapy may be needed to prevent anemia recurrence

17 American Journal of Gastroenterology 2008 May;103(5): Conclusion Ferinject Trial: FeCarb (Ferinject) is non-inferior to FeSulf FeCarb is safe Faster hemoglobin increase Convenient administration of high doses of iron

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20 Bone Remodeling Osteoclasts followed by osteoblasts Act on the same bone surface

21 Osteoporose Definisjon Osteoporose er en sykdom karakterisert ved reduksjon i beinmasse og ødelagt mikroarkitektur, hvilket medfører økt skjørhet av skjelettet og derfor større risiko for brudd

22 Kompresjonsfrakturer

23 Trabekulært bein Normalt Osteoporose

24 Osteoporosis

25 Osteoporose vs. osteomalaci Normalt ben Osteoporose Osteomalaci Ben mengde Normal Redusert Normal % Mineral Normal Normal Redusert

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27 Benmineraltetthetsmåling DXA QUS

28 Definition of osteoporosis BMD Normal - 1 SD Topp ben masse Lav benmasse (Osteopeni) SD Ingen brudd Med brudd Osteporose Alvorlig osteoporose

29 Possible causes Corticosteroids Vitamin D deficiency and disturbances of calcium metabolism Sex hormone deficiency Smoking Poor nutritional status Disease activity

30 Bone Mineral Density and Bone Metabolism in Patients with Inflammatory Bowel Disease: A population-based Study J.Jahnsen, J.A.Falch*, P.Mowinckel**, E.Aadland Medical Department and *Hormone Laboratory, Aker University Hospital, **Foundation for Healthservices Research, Central hospital of Akershus, Norway. AKER UNIVERSITY HOSPITAL UNIVERSITY OF OSLO

31 Aims Compare bone mineral density (BMD) in patients with Crohn s disease with patients with ulcerative colitis and healthy subjects Evaluate possible risk factors for bone loss in inflammatory bowel disease

32 Materiale HS UC CD Antall personer Menn/Kvinner 24/36 24/36 24/36 Post/premenopause 7/29 7/29 7/29 Alder (median og 36(21-75) 38(21-75) 36(21-75) spredning)

33 80 År Alder Kvinner Menn HS UC CD

34 Utbredning CD UC Tynntarm Tynn- og tykktarm Tykktarm Proctitt Proctosigmoiditt Ve. sidig Pan- /substantial Tynntarmsreseksjon hos 27 pasienter

35 BMI (Mean, 95% Konfidensintervall) kg/m p= p= HS UC CD

36 Resultater UC CD PTH (pmol/l) OHVitD3 (nmol/l) a Ca (mmol/l) a Osteocalcin (nmol/l) ALP (U/l) b Albumin (g/l) c U-Pyridinoline a p<0.05 b p<0.01 c p<0.001

37 25-hydroksyvitamin D nmol/l 140 Vitamin D status Kvinner Menn CD UC

38 PTH (pmol/l) p= PTH in CD 15 patients Small bowel - Small bowel resections resections (n= 27) (n= 33)

39 PTH Relationship between Vitamin D and PTH in CD patients pmol/l small bowel res. - small bowel res hydroxyvitamin D nmol/l

40 Konklusjon Pasienter med Crohn s sykdom har økt prevalens av osteopeni og osteoporose Årsaken synes å være multifaktoriell Redusert BMD hos pasienter med Crohn s sykdom, er knyttet til bruk av corticosteroider

41 Konklusjon Vitamin D mangel er vanlig hos pasienter med Crohn s sykdom Crohn pasienter operert med tynntarmsreseksjon har økt risiko for å utvikle sekundær hyperparathyreoidisme og lav BMD

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