What is the relationship between gastric ulcers, avascular necrosis, and osteoporosis?

From the Guidelines

Gastric ulcer, avascular necrosis, and osteoporosis are likely complications of long-term corticosteroid therapy or gastrointestinal diseases, and patients should receive prophylactic medications to prevent these complications, prioritizing calcium and vitamin D supplementation, as well as bisphosphonates for those at high risk of osteoporosis, as recommended by recent guidelines 1.

Prevention of Complications

To prevent gastric ulcers, a proton pump inhibitor such as omeprazole 20mg daily or pantoprazole 40mg daily can be prescribed. For osteoporosis prevention, the following are recommended:

• Calcium supplementation (1000-1200mg daily)
• Vitamin D (800-1000 IU daily)
• Consideration of bisphosphonates like alendronate 70mg weekly for those at high risk, as supported by evidence from studies on glucocorticoid-induced osteoporosis 1.

Avascular Necrosis Prevention

For avascular necrosis prevention, there is no specific prophylaxis, but minimizing steroid dose and duration is crucial, as suggested by the most recent guidelines on osteonecrosis management 1.

Monitoring and Intervention

Patients should be monitored regularly with bone density scans every 1-2 years while on long-term steroids, and early recognition through regular monitoring and prompt intervention are essential to prevent permanent damage from these serious complications, as emphasized by the American Gastroenterological Association medical position statement on osteoporosis in gastrointestinal diseases 1. Some key points to consider in managing osteoporosis in GI disease include:

• All patients should receive education on lifestyle changes, such as regular weight-bearing exercise, quitting smoking, and avoiding excessive alcohol intake, as well as vitamin D and calcium supplementation 1.
• DXA scans should be selectively ordered in patients based on a thorough risk factor assessment, including those with a history of gastrectomy, particularly postmenopausal females, males over age 50, and patients with low-trauma fractures 1.

From the FDA Drug Label

Gastric or duodenal ulcers, some severe and with complications, have also been reported [see Dosage and Administration (2.6); Warnings and Precautions (5. 1)]. Musculoskeletal: bone, joint, and/or muscle pain, occasionally severe, and incapacitating [see Warnings and Precautions (5. 3)]; joint swelling; low-energy femoral shaft and subtrochanteric fractures [see Warnings and Precautions (5. 5)].

• Gastric Ulcer: Alendronate may cause gastric or duodenal ulcers, some of which can be severe and have complications.
• Avascular Necrosis: The label mentions localized osteonecrosis of the jaw, which is a form of avascular necrosis, generally associated with tooth extraction and/or local infection with delayed healing 2.
• Osteoporosis: Alendronate is used to treat osteoporosis, but the label also mentions that it may cause low-energy femoral shaft and subtrochanteric fractures, which is a concern in patients with osteoporosis 2.

From the Research

Gastric Ulcer

• Gastric ulcers are a type of peptic ulcer disease, which affects 1% of the population in the US 3
• The principal causes of peptic ulcer disease are Helicobacter pylori infection and aspirin or nonsteroidal anti-inflammatory drug (NSAID) use 3
• Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks 3

Avascular Necrosis

• Avascular necrosis is an ischemic or cytotoxic necrosis of epiphyseal bone, responsible for joint pain and altered life quality 4
• Avascular necrosis can be unifocal or multifocal, and involves the femoral head in more than 75% of cases 4
• Risk factors for avascular necrosis include corticosteroid treatment, hypercholesterolemia, sickle cell disease, and alcohol abuse 4, 5
• MRI imaging is the main exploration for the diagnostic and staging of the disease 4

Osteoporosis

• There is no direct evidence in the provided studies to discuss osteoporosis in relation to gastric ulcers and avascular necrosis
• However, it is known that long-term corticosteroid use, which is a risk factor for avascular necrosis, can also contribute to osteoporosis 4, 5

Relationship between Gastric Ulcer, Avascular Necrosis, and Osteoporosis

• While there is no direct relationship between gastric ulcers and avascular necrosis, both conditions can be related to corticosteroid use 4, 3
• Osteoporosis can be a secondary effect of long-term corticosteroid use, which is a risk factor for avascular necrosis 4, 5
• Proton pump inhibitors (PPIs) can be used to prevent gastrointestinal lesions induced by non-steroidal anti-inflammatory drugs (NSAIDs), which can be used to treat pain associated with avascular necrosis 6