A Review of Musculoskeletal Extraintestinal Manifestations of IBD

In her presentation at the Advances in Inflammatory Bowel Disease 2021 Meeting, Laura Raffals, MD, identified the common types of musculoskeletal conditions associated with inflammatory bowel disease (IBD), as well as how to recognize and best treat them and reviewed screening recommendations for metabolic bone diseases and risk factors for nephrolithiasis.

Laura Raffals, MD, is an associate professor at the Mayo Clinic in Rochester, Minnesota.

Of all extraintestinal manifestations (EIM) of IBD, musculoskeletal are the most frequently occurring, with peripheral arthritis being the most common. Patients with IBD can also experience axial arthritis, sacroiliitis (which is often not recognized as many patients are asymptomatic), and osteoporosis. Raffals pointed out that arthritis symptoms may precede an IBD diagnosis but can be distinguished from osteoarthritis because of a history of morning stiffness, and an improvement of symptoms with ambulation.

Patients with IBD are also at risk for metabolic bone diseases (MBD), such as osteoporosis. For the general population, risk factors of MBD include being female, early menopause, hormonal imbalances, tobacco use, and age. For patients with IBD, the risk factors include prolonged use of glucocorticoids, intestinal inflammation, malabsorption, and vitamin D and calcium deficiency.

Dr Raffals noted that of all patients with IBD who are at risk for osteoporosis and low bone mineral density, only 23% are screened for MBD. She reviewed the screening recommendations of both the American College of Gastroenterology (ACG) and the National Osteoporosis Foundation.

The ACG recommends dual-energy X-ray absorptiometry (DEXA) scans in all patients with IBD who have 1 or more of the following risk factors: postmenopausal female, males aged 50 and older, a history of vertebral fractures, chronic corticosteroid use, or hypogonadism. If the initial scan is normal, the recommendation is for a DEXA scan every 2-3 years after.

The National Osteoporosis Foundation recommends DEXA scanning for postmenopausal women aged 65 and men aged 70 and older. If the patient has osteoporosis at the initial scan, a scan should be done every 2 years, or, if they are being treated for osteoporosis, every year. If there is no osteoporosis at the initial scan and there are no changes to risk factors, scanning can be done every 5-10 years, depending on other clinical factors.

Dr Raffals also highlighted a common secondary manifestation of IBD, nephrolithiasis, also known as IBD stones, which 12% to 28% of patients with IBD are at risk of developing. Patients who have undergone extensive small bowel resection or have small bowel disease are at increased risk of nephrolithiasis. Dr Raffals stated that clinicians should take care with treatment of MBD, as excessive calcium intake can result in nephrolithiasis.

—Allison Casey

Raffals L. IBD Rolling stones and bones. Presented at: Advances in Inflammatory Bowel Disease annual meeting. December 9-11. Orlando, Florida.