%PDF-1.4 % 12 0 obj <> endobj 70 0 obj <>stream /Artifact <>BDC q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 1 .1 0 .1 k /GS1 gs .015015 0 595.29 31.48 re f EMC /P <>BDC BT /TT4 1 Tf 46 0 0 46 37.6675 670.7389 Tm 1 .89 0 0 k 0 Tc 0 Tw (Metabolic )Tj ET EMC /P <>BDC BT 46 0 0 46 37.6675 626.5391 Tm (Bone Disease)Tj ET EMC /Figure <>BDC Q q 1 i 480.855 791.282 99.247 -87.11 re 339.363 626.539 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS1 gs q 90.236 0 0 87.548 488.367 703.974 cm /Im1 Do Q EMC /Artifact <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 1 .89 0 0 k /GS1 gs q 1 0 0 1 298.526 598.902 cm 0 0 m 257.014 0 l 258.58 0 259.849 -1.2693 259.849 -2.835 c 259.849 -118.277 l 259.849 -119.843 258.58 -121.112 257.014 -121.112 c -257.014 -121.112 l -258.58 -121.112 -259.849 -119.843 -259.849 -118.277 c -259.849 -2.835 l -259.849 -1.2693 -258.58 0 -257.014 0 c h f* Q EMC /P <>BDC BT /TT2 1 Tf 11 0 0 11 61.6931 567.6203 Tm 0 0 0 0 k -.0092 Tc -.0325 Tw (Metabolic bone disease \(MBD\) encompasses conditions that result from changes in the homeostasis)Tj ET EMC /P <>BDC BT 11 0 0 11 537.6813 567.6203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.6931 551.6203 Tm -.0317 Tw (of skeletal bone caused by defects in bone density or bone mineralisation. Osteoporosis is a defect)Tj ET EMC /P <>BDC BT 11 0 0 11 537.6829 551.6203 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.6931 535.6203 Tm .0296 Tw (of bone mineral density \(BMD\). It occurs in 57-88% of adults and 16-25% of children with chronic)Tj ET EMC /P <>BDC BT 11 0 0 11 537.683 535.6203 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.6931 519.6203 Tm .0047 Tc .0648 Tw (intestinal failure \(CIF\). Osteomalacia is a defect in bone mineralisation. It is much less reported)Tj ET EMC /P <>BDC BT 11 0 0 11 537.6835 519.6203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 541.5037 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 545.3239 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 549.144 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 552.9642 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 556.7844 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 560.6046 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 564.4248 519.6203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.6931 503.6203 Tm (but could occur in up to 75% of patients on home parenteral nutrition \(HPN\).)Tj ET EMC /P <>BDC BT 11 0 0 11 431.6218 503.6203 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 39.993 461.5117 Tm 1 .89 0 0 k (Key points)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 101.3348 461.5117 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 446.6771 Tm (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 446.6771 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 446.6771 Tm (The common reasons for bone mineral loss are general or related )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 434.6771 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 434.6771 Tm (to underlying disease rather than CIF/HPN. )Tj ET EMC /P <>BDC BT 8 0 0 8 206.5193 434.6771 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 417.0078 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 417.0078 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 417.0078 Tm [(A)55.2( fracture risk assessment should be made, typically using the )]TJ ET EMC /P <>BDC BT 8 0 0 8 49.109 405.0078 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 405.0078 Tm (FRAX)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 72.6676 407.3327 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 76.2043 405.0078 Tm ( tool, and may require a dual-energy X-ray absorptiometry )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 393.0078 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 393.0078 Tm [(\(DXA\) to adjust risk propensity)74.2(. )]TJ ET EMC /P <>BDC BT 8 0 0 8 163.2223 393.0078 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 375.3385 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 375.3385 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 375.3385 Tm [(T)37.1(reatment of osteopenia/osteoporosis starts with recommendations )]TJ ET EMC /P <>BDC BT 8 0 0 8 49.109 363.3386 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 363.3386 Tm (to stop smoking, reduce alcohol, increase weight bearing exercise )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 351.3386 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 351.3386 Tm [(and have some sunlight exposure. )18.1(Then ensuring adequate )]TJ ET EMC /P <>BDC BT 8 0 0 8 49.109 339.3386 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 339.3386 Tm (\(adjusted according to concentrations\) vitamin D \(800 units or )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 327.3386 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 327.3386 Tm (greater\), calcium \(700-1200mg daily\) and magnesium through )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 315.3386 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 315.3386 Tm (oral/enteral or parenteral intake. Biphosphonates may be needed )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 303.3385 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 303.3385 Tm (if osteoporotic.)Tj ET EMC /P <>BDC BT 8 0 0 8 103.359 303.3385 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 285.6692 Tm (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 285.6692 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 285.6692 Tm (Causative medication, when possible, is reduced \(e.g. )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 273.6692 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 273.6692 Tm (corticosteroids, anticoagulants and proton pump inhibitors\).)Tj ET EMC /P <>BDC BT 8 0 0 8 260.7809 273.6692 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 255.9999 Tm (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 255.9999 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 255.9999 Tm [(Underlying inflammatory conditions must be controlled as a priority)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 288.6208 255.9999 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 238.3306 Tm (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 238.3306 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 238.3306 Tm -.005 Tc (Adequate vitamin D concentrations are ensured, and the parathyroid)Tj ET EMC /P <>BDC BT 8 0 0 8 291.0642 238.3306 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 226.3306 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 226.3306 Tm (hormone \(PTH\) plasma concentration is checked.)Tj ET EMC /P <>BDC BT 8 0 0 8 226.9645 226.3306 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 208.6613 Tm (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 208.6613 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 208.6613 Tm (All patients with CIF should have a bone density assessment using )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 196.6613 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 196.6613 Tm [(DXA)55.2( initially and repeated every 3-5 years.)]TJ ET EMC /P <>BDC BT 8 0 0 8 202.5231 196.6613 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 178.992 Tm (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 178.992 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 178.992 Tm (The amount of available functional intestine must be considered )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 166.992 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 166.992 Tm (when choosing treatment options \(e.g. oral vs. parenteral )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 154.992 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 154.992 Tm (bisphosphonates\). )Tj ET EMC /P <>BDC BT 8 0 0 8 118.9333 154.992 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 137.3227 Tm (9.)Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 137.3227 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 137.3227 Tm (Referral to a metabolic bone specialist should be recommended )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 125.3227 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 125.3227 Tm [(if the )18.1(T)18.1( score is decreasing despite treatment.)]TJ ET EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 212.8981 125.3227 Tm 1 .89 0 0 k ( )Tj ET EMC /P <>BDC BT 12 0 0 12 39.993 104.9841 Tm (Explanations)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 114.6766 104.9841 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 39.993 90.1494 Tm -.005 Tc (1.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 49.149 90.1494 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 51.3317 90.1494 Tm -.005 Tc (Metabolic bone diseases \(MBD\) are conditions that result in changes)Tj ET EMC /P <>BDC BT 8 0 0 8 292.3367 90.1494 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 78.1494 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 78.1494 Tm -.005 Tc [(in the homeostasis of skeletal bone. )18.1(They result in firstly)74.2(, pathological)]TJ ET EMC /P <>BDC BT 8 0 0 8 293.1359 78.1494 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.109 66.1494 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 51.3317 66.1494 Tm -.01 Tc [(bone density defects, such as osteoporosis, osteopetrosis or Paget)18.1(s.)]TJ ET EMC /P <>BDC BT 8 0 0 8 291.1428 66.1494 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 464.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 464.4238 Tm [(Secondly)74.2(, they can be caused by defects of bone mineralisation, )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 452.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 452.4238 Tm [(such as Ricket)18.1(s, osteomalacia and renal osteodystrophy)74.2(. MBD )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 440.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 440.4238 Tm (results from two main processes: Dynamic changes in serum )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 428.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 428.4238 Tm (calcium, phosphate and their controlling hormones, vitamin D or )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 416.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 416.4238 Tm (parathyroid hormone \(PTH\), leads to alteration in hydroxyapatite )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 404.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 404.4238 Tm [(concentrations of calcium or phosphate. )55.2(Alternatively)74.2(, dynamic )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 392.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 392.4238 Tm (alterations occur in bone turnover or growth. Osteomalacia presents)Tj ET EMC /P <>BDC BT 8 0 0 8 557.0892 392.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 380.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 380.4238 Tm (with bone or muscle pain and radiological features include Looser )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 368.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 368.4238 Tm (zones in adults and wide growth plates and frayed metaphyses is )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 356.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 356.4238 Tm (consistent with rickets in children.)Tj ET EMC /P <>BDC BT 8 0 0 8 435.2376 356.4238 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 338.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 338.7546 Tm (The general causes/underlying disease responsible include: )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 326.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 326.7546 Tm [(older age/female, reduced physical activity)74.2(, low sunlight exposure, )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 314.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 314.7546 Tm (smoking/alcohol, chronic inflammation and medication \(e.g. )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 302.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 302.7546 Tm (corticosteroids, long-term anticoagulation \(e.g. heparin\) or proton )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 290.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 290.7546 Tm (pump inhibitors\). )Tj ET EMC /P <>BDC BT 8 0 0 8 377.8822 290.7546 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.1843 273.0852 Tm (2.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 314.3002 273.0852 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 316.5228 273.0852 Tm (Calculation of 10-year major osteoporotic fracture risk and hip )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 261.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 261.0852 Tm (fracture risk is calculated using the FRAX)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 462.8041 263.4102 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 466.3408 261.0852 Tm [( tool. )18.1(This should be )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 249.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 249.0852 Tm (undertaken in post-menopausal women and men aged 50 or more )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 237.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 237.0852 Tm (who have risk factors for fracture, recent or current long-term oral )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 225.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 225.0852 Tm [(glucocorticoid therapy)74.2(, or a bone mineral density )18.1(T)55.2(-score )]TJ /TT1 1 Tf 25.3091 0 TD <0003>Tj /TT2 1 Tf .5488 0 TD ( -2.5. )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 213.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 213.0852 Tm (If the fracture risk is intermediate, a BMD measurement should be )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 201.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 201.0852 Tm [(performed using a DXA)55.2( and then re-estimate FRAX score. )55.2(A)55.2( falls )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 189.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 189.0852 Tm (assessment should also be undertaken. In pre-menopausal women )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 177.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 177.0852 Tm (and men <50yrs, the following is a non-exhaustive list of parameters)Tj ET EMC /P <>BDC BT 8 0 0 8 557.7611 177.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 165.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 165.0852 Tm -.01 Tc (that currently fall outside of the FRAX assessment and may therefore)Tj ET EMC /P <>BDC BT 8 0 0 8 555.6484 165.0852 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 153.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 153.0852 Tm [(mandate a DXA)55.2( assessment to determine treatment thresholds: )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 141.0852 Tm ( )Tj ET EMC /P <>BDC BT /TT1 1 Tf 8 0 0 8 316.5228 141.0852 Tm <0004>Tj /TT2 1 Tf .5488 0 TD (4cm height loss, kyphosis, type 2 diabetes mellitus, inflammatory )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 129.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 129.0852 Tm (conditions, hyperparathyroidism, nutritional deficiencies, and proton )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 117.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 117.0852 Tm (pump inhibitor usage. )Tj ET EMC /P <>BDC BT 8 0 0 8 395.2377 117.0852 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 305.1843 99.4159 Tm -.015 Tc (3.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 314.4202 99.4159 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 316.5228 99.4159 Tm [(T)37.1(reatment is tailored to the individual and includes keeping plasma )]TJ ET EMC /P <>BDC BT 8 0 0 8 314.3002 87.4159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 87.4159 Tm (calcium at the upper limit of normal, correcting hypomagnesaemia )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 75.4159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 75.4159 Tm -.005 Tc [(and vitamin D deficiency)74.2(. When osteoporotic or above the treatment)]TJ ET EMC /P <>BDC BT 8 0 0 8 556.0435 75.4159 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3002 63.4159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 316.5228 63.4159 Tm (line on the FRAX score, biphosphonates are readily used. )Tj ET EMC /P <>BDC BT 8 0 0 8 525.5345 63.4159 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1643 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.78 595.29 1.417 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3571 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2006 14.3571 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 38.993 608.786 Tm 0 0 0 .8 k [(Philip )55.2(Allan, Jeremy Nightingale and the BIF)55.2(A)55.2( Committee)]TJ ET EMC /P <>BDC BT 6 0 0 6 510.4381 41.029 Tm (Continued over page...)Tj ET EMC /P <>BDC BT 8 0 0 8 523.4485 14.3585 Tm 0 0 0 0 k (January 2022)Tj ET EMC Q endstream endobj 71 0 obj <>/XObject<>/ExtGState<>>> endobj 79 0 obj <> endobj 129 0 obj <>stream /Figure <>BDC q 1 i -16 794.836 625.344 -936.03 re 297.645 420.96 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS2 gs q 702.114 106.142 -80.977 535.654 11.868 -89.181 cm /Im2 Do Q EMC /P <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS1 gs BT /TT2 1 Tf 8 0 0 8 37.8488 776.0668 Tm 0 0 0 .8 k -.015 Tc 0 Tw (4.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 47.0847 776.0668 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 49.1873 776.0668 Tm (Long term corticosteroid, proton pump inhibitor or anticoagulants )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 764.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 764.0668 Tm (\(especially heparin\) cause bone mineral loss. Hypophosphataemic )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 752.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 752.0668 Tm (osteomalacia can occur following administration of ferric-)Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 740.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 740.0668 Tm (carboxymaltose. Whilst there may be no evidence of long-term )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 728.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 728.0668 Tm (sequelae, repeated occurrence of hypophosphataemia may result )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 716.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 716.0668 Tm (in reduction in BMD. )Tj ET EMC /P <>BDC BT 8 0 0 8 123.4412 716.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 698.3975 Tm -.015 Tc (5.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 47.0847 698.3975 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 49.1873 698.3975 Tm (Patients may have an underlying inflammatory condition that )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 686.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 686.3975 Tm (both itself increases bone turnover and increases risk of exposure )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 674.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 674.3975 Tm (to corticosteroid medication. Chronic inflammatory conditions )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 662.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 662.3975 Tm (must be treated to reduce the inflammatory burden where )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 650.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 650.3975 Tm (possible.)Tj ET EMC /P <>BDC BT 8 0 0 8 80.7615 650.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 632.7281 Tm -.015 Tc (6.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 47.0847 632.7281 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 49.1873 632.7281 Tm (Adequate vitamin D concentrations are ensured and the parathyroid)Tj ET EMC /P <>BDC BT 8 0 0 8 289.3358 632.7281 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 620.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 620.7282 Tm [(hormone \(PTH\) plasma concentration is checked. )55.2(As there is a loss )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.9647 608.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 608.7282 Tm (of the diurnal parathormone rhythm with nocturnal parenteral )Tj ET EMC /P <>BDC BT 8 0 0 8 46.9647 596.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 49.1873 596.7282 Tm (nutrition \(PN\), daytime PN can be considered.)Tj ET EMC /P <>BDC BT 8 0 0 8 211.9295 596.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.0402 776.0668 Tm -.015 Tc (7.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.2761 776.0668 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.3788 776.0668 Tm [(Osteoporosis is diagnosed by DXA)55.2( scans or through assessment )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.1561 764.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 764.0668 Tm (of plain films with general loss of bone mass or fractures in common)Tj ET EMC /P <>BDC BT 8 0 0 8 554.9257 764.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 752.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 752.0668 Tm -.015 Tc [(sites. Osteopaenia is defined as a )18.1(T)55.2(-score -0.1 - -2.5 and osteoporosis)]TJ ET EMC /P <>BDC BT 8 0 0 8 554.738 752.0668 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 740.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 740.0668 Tm [(as a )18.1(T)55.2(-score <-2.5. )55.2(Although ESPEN recommends an annual DXA, )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.1561 728.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 728.0668 Tm (in the UK an annual FRAX assessment is recommended, and if an )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 716.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 716.0668 Tm [(intermediate/high risk of fracture if found, then a DXA)55.2( should be )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.1561 704.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 704.0668 Tm [(performed. )55.2(A)55.2( routine DXA)55.2( should be undertaken every 3-5 years.)]TJ ET EMC /P <>BDC BT 8 0 0 8 543.4024 704.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.0402 686.3975 Tm -.015 Tc (8.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.2761 686.3975 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.3788 686.3975 Tm (Patients with CIF may have a short or dysfunctional bowel resulting )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 674.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 674.3975 Tm (in reduced absorption of calcium, phosphate and vitamin D. )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 662.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 662.3975 Tm (The oral route may not be tolerated/appropriate thus a parenteral )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 650.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 650.3975 Tm -.005 Tc (bisphosphonates \(e.g. zoledronate\) or denosumab may be preferred.)Tj ET EMC /P <>BDC BT 8 0 0 8 555.9287 650.3975 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.0402 632.7281 Tm -.015 Tc (9.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.2761 632.7281 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.3788 632.7281 Tm (According to the National Osteoporosis Guideline Group \(NOGG\), )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 620.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 620.7282 Tm [(DXA)55.2( frequency in UK patients should follow 3-5 years of treatment, )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.1561 608.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 608.7282 Tm (unless a drug holiday occurs due to improved BMD, in which case )Tj ET EMC /P <>BDC BT 8 0 0 8 312.1561 596.7282 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.3788 596.7282 Tm [(it should be 1.5-3 years later)55.2(. )]TJ ET EMC /P <>BDC BT 8 0 0 8 419.328 596.7282 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1656 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.781 595.29 1.4171 re f EMC /Artifact <>BDC 1 .1 0 .1 k .015015 0 595.29 31.482 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3583 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2007 14.3583 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /Artifact <>BDC 0 0 0 .08 k 38 427.392 518.383 156.355 re f EMC /P <>BDC BT 9 0 0 9 55.4701 559.4822 Tm 1 .89 0 0 k (Suggested reading:)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 163.4701 559.4822 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 544.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 544.6476 Tm (Allan PJ and Lal S. Metabolic bone diseases in intestinal failure. J Hum Nutr Diet. 2020 Jun;33\(3\):423-430. doi: 10.)Tj 50.751 0 TD [(1)74.2(1)74.2(1)74.2(1/jhn.12726)]TJ ET EMC /P <>BDC BT 8 0 0 8 523.3647 544.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 532.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 532.6476 Tm [(Peters J, Robertson )55.2(A, Godavitarne C et al. Metabolic bone disease. Orthop )18.1(T)37.1(rauma. 2017; 31: 306-31)74.2(1)]TJ ET EMC /P <>BDC BT 8 0 0 8 430.7046 532.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 520.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 520.6476 Tm [(Chang CY)128.9(, Rosenthal DI, Mitchell DM et al. Imaging findings of metabolic bone disease. Radiographics. 2016; 36: 1871-87)]TJ ET EMC /P <>BDC BT 8 0 0 8 496.9661 520.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 508.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 508.6476 Tm -.005 Tc [(The International Society for Clinical Densitometry of)18.1(ficial position statement 2019. https://iscd.org/learn/of)18.1(ficial-positions)]TJ 52.4658 0 TD (/adult-positions/ )Tj ET EMC /P <>BDC BT 8 0 0 8 543.4185 508.6476 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 496.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 496.6476 Tm [(Pironi L, )55.2(Arends J, Bozzetti F et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr)55.2(. 2016; 35: 247-307)]TJ ET EMC /P <>BDC BT 8 0 0 8 487.3177 496.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 484.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 484.6476 Tm [(Kanis JA, Oden )55.2(A, Johansson H et al. FRAX and its applications to clinical practice. Bone. 2009; 44: 734-43)]TJ ET EMC /P <>BDC BT 8 0 0 8 444.6381 484.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 472.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 472.6476 Tm [(Hardy S, V)74.2(andemergel X. Intravenous iron administration and hypophosphatemia in clinical practice. Int J Rheumatol 2015; 463675)]TJ ET EMC /P <>BDC BT 8 0 0 8 527.6498 472.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 460.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 460.6476 Tm (Briot K, Roux C. Glucocorticoid-induced osteoporosis. RMD Open 2015: 1\(1\): e000014)Tj ET EMC /P <>BDC BT 8 0 0 8 371.2435 460.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 448.6476 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 63.974 448.6476 Tm [(NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis. www)55.2(.shef.ac.uk/NOGG)]TJ ET EMC /P <>BDC BT 8 0 0 8 432.1576 448.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 55.4701 436.6476 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 522.8951 14.3583 Tm 0 0 0 0 k (January 2022)Tj ET EMC Q endstream endobj 130 0 obj <>/XObject<>/ExtGState<>>> endobj 6 0 obj <> endobj 5 0 obj <> endobj 75 0 obj <>stream Adobed         #"""#''''''''''     !! !!''''''''''""  s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjzm!1AQa"q2#BRbr3$4CS%cs5DT &6E'dtU7()󄔤euFVfvGWgw8HXhx9IYiy*:JZjz?lٳ_ |6lٳf]6lٳdʾJffT OrW!>~KfKy5 xg9(vlٲ?= 8R5/2**3Oag7ռk~{ G8;aœ[, Njۭ{ٳflZ|qmd@i7i6S9?򥞮Q{j%˫D=r[{+IYxËDX@qU{āeٳflV {D6<َ5. )PHLjI 6l̓u Vқc==x& 2FR0p.zw߈ٳbyhM-nJ k@F" q1YkCTЕ-͔TڌKD΋Ywmi40G&$c1!1>)>,Kf͐4/˿=뫲⳧ݾ?ڳ'1I0-)%*6,&=6= 4Sd#ՏJ#C{yٳg"f?2_7"Rhb?PH߮;Gx*1ʁRyi:qBϛ+$kj4(1'3=>} KqF0ŏ+Gf͜cϯi .^s$Svױ_Gr/ ^\yFsi@K>eݒ.[ ~Ԯo?1<48BNO8ni|/<$$(0yu|kM}N,m98,pK̵fݛ6l"Ӽaΐ"Oo=*%u9:ԭ.m3Xt򟔴tNK+{hnڒ?ܻW@.ZyR$GJX+kmU0 9>;.ٳdW-z\F@*+!r ˍZ[@fDK#qݽ:>д3jfK0F$n4h?>fݘ/e4Qii)͎Yj>1O(7~Jٳg>ܾI$bB4}A F37OOd )Q&e*2:0j#<嘴]y5K4 i*Τz7s~L;iŬ'bjOOe}_zqG}=1.!0?f͚͜V)o4l1.,xڒիDGk #Ut]_NճepɺSދOh{ts8I?+\?!jE=CeGN;fiqY|رBczHCiWBٳaG卾^_Ei#F(-Ya]_NSO{S4ٴmZIy-1J4=x{7_tpQtLQf͛f͛<݃f͛6lثf͛6lثf͛6lثf͞ev~QЭ[Xo9/ p^[ IdUMcZҷ&-opIVK[/NG,=O2>Qc5I|Xz~f̀!`H.$O=̏R y-|Ez}R:uytǿpWΧ؍SG4[?f5>hc;˳(rf {6lͺM5Mnj_v2yo]E%{q"D} hHbmG`=[mGq@Ht-pe"Z2Hߺb¼>0(j<+  FqBT+;6lW\ KV+hE9,FuE>sbмOѽ9,ͣı滾.XeZ8E16l(w/~L~lK8r AW \HOjZM3Z|ڗo0*ݽkQ'žX58a)Deg.qvlٳҙkX25@i 5a2X>k78C`H>s]b' 1LL2r6l͛6xCSf͛6lثf͛6lثf͛6lثf͝qi׳;Qaq@P8|dEsӠ62~`灣eH2:XFz_Z͓G\Do7L4fK!N7LD轈]Bٳd[̷;wUBHI#pG|յ7rӢ њ )##z6ڇ"ިᐎ[·8_7I_6ZIw\^xʵ52ZHh{_ct]ri˓Ø 3_vlٲ9K)yMZZ;RC}e:lz:e{3b0|4W47&#j \Nb9)~Y9+SYZ? ?n>s?|I.a+*Zj/O7 ǺǶq=YoDu'&C?N._z\d+qٳf΃47OCg^ w\^ 8;+@~E4Fd[ƆQڈԟB34ũfi<٤FyniFact~J=E-;ы+92GoƧڮĈ_o6.͛66ͩMyuVVZr$i}b9EiEEYEv| -*kխⷚkAKIPRD#! 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