Northeast Florida Medicine Journal, Winter 2015

DCMS online

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Northeast Florida Medicine

Vol. 66, No. 4 2015

Inflammatory Bowel Disease

IBD is associated with the malabsorption of calcium and

vitaminD, and theremay be hypogonadism induced by these

conditions.

Screening for osteoporosis with a DEXA scan

is recommended in patients with chronic corticosteroid use,

vertebral fractures, postmenopausal women, or men over the

age of 50 with hypogonadism. Preventing bone loss is an

important goal in the treatment of these patients. Aphysician

must minimize the use of systemic corticosteroids. Regular

supplementation of vitamin D, usually in the range of 1000

international units per day, and calcium 1200 mg per day is

suggested. Bisphosphonate therapy, nasal or subcutaneous

calcitonin application, and testosterone replacement in

hypogonadal men are established approaches to prevent

serious bone loss. Weight-bearing, isotonic exercise, the

stopping of smoking, the avoidance of alcohol excess, and

maintaining adequate dietary calcium are all very beneficial.

Raloxifene, a selective estrogen receptor modulator, may

reduce or prevent further bone loss.

Rare Extraintestinal

Manifestations (EIM) of IBD

Metastatic Crohn’s disease

is a rare complication of

CD with features of cutaneous involvement. Noncaseating

granulomas will be seen. There may be a granulomatous

perivasculitis. Ulcerating nodules in the skin folds of the

anterior abdominal wall and inframammary regions may

be seen. Physicians have also seen this in the vulva, penis,

ankles, and knees. The bronchial tree and pancreas may be

involved. Treatments with steroids are effective and other

investigators have used Imuran, cyclosporin, and infliximab.

Myelodysplastic syndrome (MDS)

may develop in IBD.

The pathogenesis here is unclear. Circulating cytokines may

be a factor. TNF -alpha may be of great significance with this

syndrome. Abnormal neutrophils and/or lymphocytes found

in patients with myelodysplastic syndrome may predispose

them to chronic infections and bowel inflammation and

increase the risk of IBD. MDS should be taken into account

in IBD patients who have a normochromic and normocytic

anemia that is otherwise unexplained.

Osteonecrosis,

also termed aseptic necrosis of bone, can

involve multiple joints. The femoral heads are most com-

monly involved, followed by the femoral condyles, proximal

humerus, and talus. The prevalence rate in Crohn’s is less

than one percent.

Although many of these cases are asso-

ciated with corticosteroid therapy, this is not a prerequisite.

Patients with severe GI disease may be more susceptible.

The concurrent use of TPN with corticosteroids seems to

place the patient at an additional risk for the development

of osteonecrosis. The mechanism of steroid-induced os-

teonecrosis is unclear. It may be a multisystem illness that

impairs osteoblast function and increases susceptibility by

a second hit from that such as corticosteroids. Bone scans

are very helpful here if the disorder is suspected. MRI will

complement the detection, and the treatment is usually very

unsatisfactory. Additional treatment is protectedweight-bear-

ing, although core decompression in combinationwith bone

grafts may be needed. Arthroplasty is the most widely used

therapeutic method.

Biologic therapies for Extraintestinal

Manifestations in IBD—Where do they work?

The dimeric anti-TNF, IgG monoclonal antibody, in-

fliximab, and the recombinant anti-TNF IgG monoclonal

antibody adalimumab, are highly effective agents for the in-

duction andmaintenance of remission inmoderate-to-severe

CD and UC. In addition to clinical response and remission,

fistulas commonly will close under these drug influences,

along with provenmucosal healing and steroid sparing.

The

anti-TNF agents have been shown to be effective therapy for

a variety of these immune mediated EIMs. Infliximab and

adalimumab have beenmost thoroughly investigated in joint

disorders.

Physicians see effective treatment for rheumatoid

and psoriatic arthritis with these agents. In addition, there

has been proven rapid improvement in peripheral arthritis in

IBDpatients who had previously been refractory to steroids,

6-MP, Imuran, or methotrexate.

The axial arthropathies,

especially ankylosing spondylitis and sacroiliitis, also may

respond. In addition to induction of remission in ankylosing

spondylitis, infliximab has been shown to be effective for

maintenance of remission. Adalimumab has been shown

to be effective for the treatment of ankylosing spondylitis

in a recent multicentre randomized double blind placebo

controlled trial.

Compared to the numerous anti-TNF treatment trials in

joint disease, there have been very few looking at the effective

treatment of the muco-cutaneous diseases in IBD. However,

there appears to be a very positive experience with pyoderma

gangrenosum (PG) and erythema nodosum (EN) with both

anti-TNF inhibitors at a variety of dose interval sequences.

There have been reports of response in Sweet’s syndrome, as

well as that seen with the very ominous metastatic cutaneous

Crohn’s disease. Multiple case reports have highlighted the

efficacy of both infliximab and adalimumab for psoriasis.

As in IBD, psoriatic patients are prone to developing joint

disease which has been treated successfully with both of the

anti-TNF neutralizing antibodies.

The anti-TNF agents have also been used to treat a variety

of ocular conditions associated with IBD. Both agents can

suppress uveitis and episcleritis.