Pancreatitis and Bone Disease

Bone health is important and often overlooked in people living with pancreatitis. Those with recurrent acute pancreatitis and chronic pancreatitis face challenges that can lead to significant bone loss. Prioritizing bone health through early prevention, diagnosis, and treatment can make a huge difference in the long-term quality of life for pancreatitis patients.

What is bone disease?

Bone disease refers to a decrease in the amount of minerals in your bones (bone mineral density) and bone tissue. This leads to weakened bones that are more prone to fractures, even in scenarios where bones typically wouldn’t break.

Types of bone disease include:

  • Osteomalacia. Osteomalacia is when bones become “soft” due to a lack of mineral content but may not have a loss of bone mass, resulting in weak bones that are more likely to fracture.
  • Osteopenia. Osteopenia is a more mild degree of bone loss, which increases the risk of fractures. Those with osteopenia are at risk of developing osteoporosis.
  • Osteoporosis. Osteoporosis is a more advanced form of bone disease, characterized by significant bone loss and compromised bone strength. Those with osteoporosis have a high risk of fractures.

While everyone begins to lose bone mass as they get older, the degree of bone loss determines if someone has a bone disease. For most people, bone loss usually begins gradually in their mid-30s. By age 50, the loss of bone mass speeds up. Between the ages of 60 and 70, bone loss begins to slow down. However, certain conditions, like chronic pancreatitis, can increase the risk and rate of bone loss, leading to bone disease and fractures.

It’s important to note that the development of bone disease happens more often in women. Women begin to lose bone mass more quickly after menopause. However, men can still develop bone disease, and everyone should take care of their bone health.

Can pancreatitis lead to bone disease?

Recurrent acute pancreatitis and chronic pancreatitis (CP) increase the risk of developing bone disease. It has been reported that between 25% and 40% of CP patients suffer from bone loss. This is because chronic pancreatitis has multiple risk factors that can lead to significant bone loss.

Risk factors for bone loss in pancreatitis patients include:

  • Malabsorption/Nutritional Deficiencies. Pancreatitis can hinder fat digestion and nutrient absorption. This can cause deficiencies in micronutrients (vitamins and minerals) such as calcium, phosphorus, vitamin D, and magnesium, which may lead to a decline in bone mineral density.
  • Secondary Hyperparathyroidism. Secondary hyperparathyroidism (SHPT) is a condition that is triggered by low levels of micronutrients in blood and tissue fluids, which pancreatitis patients are at risk of. In SHPT, minerals stored in bones are pulled out into the bloodstream to correct the low levels of micronutrients.
  • Lean Body Mass Wasting. Lean body mass wasting, meaning the loss of muscle and non-fat tissues, can lead to a decline in bone density. In pancreatitis, this can result from protein and carbohydrate malabsorption, weight loss, and/or weight cycling (repeatedly losing and gaining weight).
  • Underuse of PERTs. Pancreatic enzyme replacement therapy (PERT) helps pancreatitis patients digest food and absorb nutrients. When patients don’t take enough PERT, they may not be able to absorb enough nutrients to maintain healthy bones.
  • Medications. Certain medications prescribed to pancreatitis patients, such as steroids and opioids, can contribute to factors that increase the loss of minerals in bones (bone demineralization).
  • Diabetes. Pancreatitis patients are at risk of developing diabetes (type 3c diabetes). Diabetes is a risk factor for bone loss because it can harm the structure of bones and slow down the process of rebuilding your bones as they wear down.

Other factors that can contribute to bone loss in pancreatitis include:

  • Inflammation
  • Low sex hormone levels
  • Female sex
  • Continued smoking and alcohol use

Watch our webinar on bone disease and pancreatitis.

Preventing Bone Disease

While recurrent acute pancreatitis and chronic pancreatitis patients are at risk of developing bone disease, there are ways to prevent bone loss. Focusing on building a strong skeleton now can make a big difference as you age.

Ways to prevent bone disease while living with pancreatitis include:

  • Eating a well-balanced diet. Focus on eating a well-balanced diet, with the support of PERT. Include foods high in protein, calcium, and vitamin D. Use nutritional supplements as needed, with the guidance of a health care professional.
  • Building Muscle. Increase your lean body mass by adding 20 to 30 minutes of weight-bearing exercises to your daily routine. We recommend checking with your doctor before starting any new exercise routine.
  • Dosing PERT correctly. Using the right dose of PERT helps your body absorb nutrients correctly and reduce the risk of deficiencies. Patients should adjust their doses based on symptoms, weight, and the foods they’re eating.
  • Avoiding Smoking and Alcohol. Smoking and alcohol contribute to bone loss by increasing the risk of fractures, delaying bone healing, and interfering with nutrient absorption.

Learn more about dosing PERT.

Symptoms of Bone Disease

Bone disease is often called a “silent” disease because there are usually no signs until a bone breaks. As a result, it’s important for people with chronic pancreatitis to start thinking about their bone health early and work with their doctor to check bone density levels as needed.

Symptoms of bone disease may include:

  • Fractures (broken bone)
  • Slower bone healing after a fracture
  • Stooped posture (spinal deformity/curvature)
  • Bone pain (in osteomalacia)

People with bone disease are prone to both traumatic fractures (breaks due to significant or extreme force to bone) and spontaneous fractures (breaks without a significant or extreme force to bone).

Fractures more likely to occur in osteoporosis include:

  • Hip fractures
  • Spinal fractures
  • Lower back (lumbar) fractures
  • Lower leg fractures (tibia/fibula)
  • Kneecap (patella) fractures
  • Rib fractures
  • Sacrum fractures
  • Arm fractures (when an open skin wound is present)

Diagnosing Bone Disease

Those with recurrent acute pancreatitis, chronic pancreatitis, or a symptom of bone disease should have their bone density tested. A Dual-Energy X-Ray Absorptiometry (DEXA/DXA) is the commonly used test for checking bone health. It’s a low-dose X-ray that measures bone density in the hips and spine. The results, represented as a T-score or Z-score, show the difference between the patient’s bone health and what’s considered healthy for their age and sex.

T-scores and classification of bone disease are as follows:

Normal-1.0 or greater
OsteopeniaBetween -1.0 and -2.5
Osteoporosis-2.5 or less
Severe Osteoporosis-2.5 or less and fragility fracture

Some DEXA scans now include a Trabecular Bone Score (TBS). This tool examines the texture of bones in the spine (vertebrae), helping to identify potential issues in the bone structure even if there hasn’t been a significant loss in bone density levels.

Monitoring Bone Disease

If you do have bone loss, your doctor may recommend blood and urine tests to determine what factors are influencing your bone health and how well you’re forming bone. These tests look at the following:

  • Calcium, phosphorous, and magnesium levels
  • Kidney function
  • Alkaline phosphatase levels
  • Blood protein levels
  • Vitamin D levels
  • Parathyroid and other hormone levels
  • Markers of bone formation
  • Markers of bone resorption

These tests are typically not recommended to diagnose bone disease, but they can be used in addition to a DEXA scan to get a comprehensive picture of your bone health.

How often should pancreatitis patients be tested for bone disease?

The frequency of bone disease screening is determined by whether or not pancreatitis patients have been diagnosed with bone loss. Bone disease screening is typically:

  • Yearly. Patients with existing bone loss or those undergoing treatment for bone disease should undergo yearly screening.
  • Every Two Years. Chronic pancreatitis patients with normal bone density should be screened every two years.

Follow-up bone density screening should be performed when the results will influence patient management. Any other testing frequency would be determined by your doctor.

Treating Bone Disease

The first step in treating bone disease is to identify and address the causes of bone loss. For people with pancreatitis, this often means correcting nutrient deficiencies with the right diet and taking the correct dose of Pancreatic Enzyme Replacement Therapy (PERT). It also involves making sure the balance between calcium, vitamin D, and parathyroid hormone (Ca-Vit D-PTH axis) is optimized for your overall bone health.

Once deficiencies and the Ca-Vit D-PTH axis are corrected, your doctor will consider medications based on your T-score, fracture risk, or the presence of a bone fracture.

Medications used to treat osteoporosis include:

  • Antiresorptive Medication. Antiresorptive medications work by stabilizing bone metabolism and preventing bone loss, helping to maintain or improve bone density over time.
  • Anabolic Medication. Anabolic medications work by inducing new bone formation, meaning they stimulate the creation of fresh bone tissue. This process helps increase bone density and strength, making bones less prone to fractures and contributing to overall bone health.

Examples of antiresorptive medications include:

  • Fosomax (alendronate)
  • Reclast (zoledronic acid)
  • Boniva (ibandronate)
  • Prolia and Xgeva (denosumab)

Examples of anabolic medications include:

  • Forteo (teriparatide)
  • Tymlos (abaloparatide)
  • Evenity (romosozumab)

Osteoporosis medications have an excellent safety profile, but since they are taken on a long-term basis, treated patients should be regularly monitored by their doctor.

Key Takeaways

  • Bone disease is a condition where bones lose minerals and mass, making them more prone to break.
  • Recurrent acute pancreatitis and chronic pancreatitis increase the likelihood of bone disease due to risk factors such as malabsorption/nutritional deficiencies, secondary hyperparathyroidism, lean body mass wasting, underuse of PERTs, certain medications, and diabetes.
  • Pancreatitis patients can prevent bone disease by eating a well-balanced diet, building muscle, dosing PERT correctly, and avoiding smoking and alcohol.
  • Bone disease often has no symptoms until there’s a broken bone. Symptoms of bone disease may include fractures, slow bone healing, stooped posture, and bone pain.
  • Those with recurrent acute pancreatitis, chronic pancreatitis, or a symptom of bone disease should have their bone density tested with a DEXA scan. Blood tests and urine tests can also help patients and doctors understand overall bone health.
  • Treating bone disease may involve correcting nutritional deficiencies, optimizing the Ca-Vit D-PTH axis, and using osteoporosis medications.

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