CORRESPONDENCE Readers may submit letters to the editor concerning articles that appeared in GASTROENTEROLOGY within one month of publication. Detailed guidelines regarding the content are included in the Instructions to Authors. Bone Health Guidelines for Patients With Chronic Pancreatitis Dear Sir: We noted with interest the recent article published in GASTROENTEROLOGY by Prof Forsmark on the clinical man- agement of chronic pancreatitis. 1 The author recommended the inclusion of bone health as a key aspect for medical therapy in this group—a vitally important and, up to now, neglected area of chronic pancreatitis management. Osteopenia or osteoporosis are complications of chronic pancreatitis for two-thirds 2 of patients but may, in fact, be present in more than 3 in 4 patients in some populations. 3,4 Prof Forsmark stated that osteopathy is seen in those with exocrine insufficiency, but in reality, it appears to be present even in those without significant exocrine impairment. 2 While the pathogenesis of bone demineralization in this group has not been characterized, contributory factors include smoking, poor diet, and low sunlight exposure. The American Gastroenterological Association (AGA) recommended that patients with gastrointestinal condi- tions (inflammatory bowel disease [IBD], celiac disease and post-gastrectomy) should undergo bone density assessment by dual-energy X-ray absorptiometry (DXA) if they have at least one additional osteoporosis risk factor (previous low-trauma fracture, post-menopausal women, hypogonadism, or patients on corticosteroid therapy in IBD). 5 Chronic pancreatitis was not considered by the AGA in its bone health guidelines, likely due to a lack of studies at that time. While baseline DXA for all patients with chronic pancreatitis would be the most preferable method of screening for osteoporosis in this group, the AGA stated that to recommend bone density assessment for all patients would result in numerous unnecessary tests. At the very least for patients with chronic pancreatitis, it seems prudent to recommend a DXA for post-menopausal women, those with a previous low-trauma fracture, and men over 50 years, as well as those with malabsorption. For bone health, all patients with chronic pancreatitis should be counseled on basic preven- tative measures, including adequate dietary calcium and vitamin D, weight-bearing exercise, and smoking/alcohol avoidance. In line with the AGA recommendations for gastrointestinal diseases, those with osteopenia should undergo repeat DXA after 2 years, while those with osteoporosis (and those with vertebral compression fractures regardless of DXA) should receive appropriate medication and screening for other causes or be referred to a bone specialist for further evaluation. 6 These measures are critical for reducing the burden of osteoporosis and increased fracture risk 5 for this nutritionally vulnerable patient group. SINEAD N. DUGGAN KEVIN C. CONLON Centre for Pancreatico-Biliary Diseases Department of Surgery Trinity College Dublin Dublin, Ireland 1. Forsmark CE. Gastroenterology 2013;144:1282–1291. 2. Duggan SN, et al. Clin Gastroenterol Hepatol 2013 Jul 12 [Epub ahead of print]. 3. Haaber AB, et al. Int J Pancreatol Feb 2000;27:21–27. 4. Duggan SN, et al. Pancreas 2012;41:1119–1124. 5. Tignor AS. Am J Gastroenterol 2010;105:2680–2686. 6. American Gastroenterological Association Medical Position State- ment: Guidelines on Osteoporosis in Gastrointestinal Diseases. Gastroenterology 2003;124:791–794. Conflicts of interest The authors disclose no conflicts. http://dx.doi.org/10.1053/j.gastro.2013.06.058 Reply. I thank Drs Duggan and Conlon for their comments on my recent review on the clinical management of chronic pancreatitis. 1 They correctly point out that osteopenia and osteoporosis may be present in those with chronic pancreatitis but without obvious exocrine insufficiency, and I would alert those interested in this topic to a recent review from these authors. 2 The consequences of osteoporosis and fracture risk in these patients are well documented. 3 Certainly the coexistence of exocrine insufficiency and osteopathy is well established, 4 and the difficulty in documenting the presence of exocrine insufficiency due to limitations in currently available diagnostic testing reinforce the points made by Drs Duggan and Conlon. I recommended baseline bone mineral density testing for all patients with chronic pancreatitis as a reasonable step in management, although space limitations did not allow me to go into more detail on this point. Drs Duggan and Conlon provide some reasonable recommendations that those with chronic pancreatitis, irrespective of the presence of documented exocrine insufficiency, undergo bone mineral density testing if they have an additional risk factor for osteoporosis. Whether selective testing or routine testing in these patients is most effective is not known, but the disease is relatively rare, which would limit the costs to the health care system for any potentially unnecessary tests. The letter from Drs Duggan and Conlon should alert clinicians to the frequency, severity, and consequences of osteoporosis in patients with chronic pancreatitis. GASTROENTEROLOGY 2013;145:911–912