Osteoporosis is a common complication of ulcerative colitis (UC). It can also be a side effect of UC treatment. There are proactive steps you can take and treatment options that can lower your risk.

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that affects the lining of the gut. It’s caused by an overactive immune system, resulting in inflammation and damage to the walls of the large intestine.

Many people with UC experience other complications as a result of this inflammation and intestinal damage, including osteoporosis.

Osteoporosis is a condition where the bones become weak, thin, and fragile over time. This happens because the body loses too much bone mass, makes too little bone mass, or both. As a result, the bones break more easily, even from minor falls, bumps, or sometimes just from everyday movements and activities.

Estimates of osteoporosis prevalence vary considerably, but up to 70% of people with IBD also have osteoporosis, with slightly lower rates observed in people with UC compared to Crohn’s disease (another form of IBD).

Osteoporosis can have important effects on the health and well-being of people with IBD. Studies estimate that people with IBD are around 40% more likely to have a bone fracture compared with their unaffected counterparts.

In this article, we take a look at the link between UC and osteoporosis, including what causes bone loss in UC and how to prevent it.

While UC itself doesn’t directly cause osteoporosis, a variety of factors may contribute to bone loss with the condition, including both the disease itself and treatment.

Steroids are a class of medications commonly used to reduce inflammation in UC. One of the side effects of these drugs, though, is bone loss, which can increase the likelihood of developing osteoporosis.

Research has found that steroid use is one of the leading risk factors for developing osteoporosis in IBD.

Long-standing disease has also been found to be a strong predictor of osteoporosis risk in IBD, which may be due to the chronic inflammation experienced over the course of the disease.

Many of the inflammatory molecules linked to IBD and UC have also been found to impact bone metabolism, which may contribute to bone loss associated with these diseases.

Nutritional deficiencies — caused either by dietary changes or lack of sun exposure — can also impact bone health. Low levels of calcium and vitamin D may be especially problematic.

Questions to ask a doctor

  • How can the medications I take for ulcerative colitis affect my bone health, and are there alternatives?
  • What tests should I have regularly to track both my bone density and inflammation, and how often should these tests be performed?
  • Are there signs or symptoms that would tell me I am developing osteoporosis?
  • If I need steroids for a UC flare, how can we minimize the impact on my bones during and after treatment?
  • Would you recommend a referral to a bone specialist to coordinate my care?

Most people with osteoporosis don’t have any symptoms and may not be aware they have the disease. In many cases, osteoporosis isn’t detected until someone breaks a bone.

Given their increased likelihood of developing osteoporosis, experts suggest that people with UC and IBD take a more proactive approach to screening than is generally recommended.

The American College of Gastroenterology (ACG) recommends that everyone taking oral steroids — especially those who have been taking them for longer than 3 consecutive months — undergo a bone mineral density (BMD) assessment using bone imaging, repeated periodically to monitor for changes.

The Crohn’s & Colitis Foundation, on the other hand, recommends screening if any osteoporosis risk factors are present, such as:

  • low body mass index (BMI)
  • prolonged steroid use
  • history of smoking
  • postmenopausal status
  • hypogonadism

According to the Crohn’s & Colitis Foundation recommendations, screening should be repeated at least every 5 years (more often if bone loss is detected).

There are simple steps all people can take to improve their bone health, like:

  • keeping physically active
  • stopping or avoiding smoking
  • limiting alcohol consumption
  • eating a diet rich in vitamin D, calcium, and protein

People with UC may consider additional steps to help prevent osteoporosis. For instance, many foods rich in calcium (like dairy products) can be triggering for some.

A registered dietitian, particularly one specializing in IBD, can help ensure you’re getting the nutrients you need for proper bone health while also helping to avoid disease flares caused by diet.

It’s important to consult a medical professional for guidance when making any changes to diet or medications, including nutritional supplements.

Questions to ask a dietitian

  • What are the best calcium- and vitamin D-rich foods I can add to my diet without triggering UC symptoms?
  • Are there specific foods or food groups I should avoid because they may weaken my bones?
  • Can you help me create a daily meal plan that incorporates gut-friendly foods and nutrients essential for bone health?
  • Are there any supplements you’d recommend, or should I try to meet my needs mostly through a balanced diet?

Additionally, people at risk for osteoporosis may want to talk with their gastroenterologist about alternatives to steroids that can help control their symptoms.

Biologic therapies, for example, are another treatment option for UC. In a 2021 study involving more than 112,000 people with UC, rates of both osteoporosis and bone fractures were lower in people who were receiving a biologic therapy than in those taking different kinds of therapies, including steroids.

You may also consider other steroid-sparing treatment options, such as immunomodulators. If a steroid is needed, a locally acting formula (budesonide) may be considered to minimize off-target effects.

If osteoporosis or osteopenia (low bone mineral density, BMD) is already present, certain medications can help prevent or potentially slow the progression of bone loss. These include:

  • bisphosphonates
  • calcitonin
  • hormone therapy
  • parathyroid hormone
  • RANKL blockers
  • sclerostin inhibitors

Your IBD care team or primary care doctor can help determine if osteoporosis medication is needed. If your gastroenterologist is not the one prescribing these medications, be sure to let them know at your next visit.

Find a medical specialist in your area today

Your healthcare team may comprise several people who can provide support.

Sometimes, a medical specialist will be required to help diagnose, manage, or treat a healthcare condition.

You can find the following medical specialists in your area today by clicking on the links:

Osteoporosis is a common complication of UC. Its treatment can also lead to bone fractures if not detected and treated promptly.

People with UC can take a variety of steps to protect their bone health, including getting active, eating a bone-healthy diet, and talking with their doctor about medications or supplements.

If you’re concerned about your bone health with UC, your healthcare team can help you determine if imaging is needed to evaluate your bone density and assess your bone health.