Common Micronutrient Deficiencies in IBD Educational Resource for Healthcare Providers

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Fact Sheet Common Micronutrient Deficiencies in IBD Educational Resource for Healthcare Providers

Inflammatory Bowel Disease (IBD) patients are at risk for micronutrient deficiencies as a result of active bowel inflam- mation, food avoidance, and medical or surgical treatments. The most common micronutrient deficiencies in IBD are listed in the table below. These deficiencies can increase risk for bone disease, cognitive decline, anemia, arterial and venous thromboembolism, poor growth, and other complications.

Most IBD patients should take a multiple vitamin with minerals daily (caution in those with liver or renal impairment)1; consider chewable or liquid form for better absorption for patients with more severe disease. Adequate intake of calcium and supplementation with vitamin D is important for all patients with IBD, especially if on high dose or long term steroids, or if avoiding dairy products. Consider water-miscible A, D, E, K if on cholestyramine, or if fat malabsorption present.

Micronutrient Signs of deficiency Risk factor for deficiency Biochemical Assessment Recommended replace- ment for deficiency

Calcium Hypotension, pro- Vitamin D deficiency, Serum calcium does not Gender and age specific: longed QT interval, decreased PTH activity,2 fluctuate with changes in • 9-18 yrs: 1300 mg distal extremity corticosteroid use calcium intake3 • 19-50 yrs: 1000 mg parasthesias, Chvostek • 51-70 yrs: sign, Trousseau sign, 1000 mg (male), muscle cramps, tetany, 1200 mg (female) seizures2 • 71+ years: 1200 mg3

Cobalamin Cognitive decline, Crohn’s disease affecting High serum Methylmalo- oral B12 supplementa- (B12) cardiovascular disease, the terminal ileum; ileal nic Acid, low plasma or tion >1000 mcg daily.4 bone fractures; mega- resection >20cm; signif- serum B12, elevated MCV Prophylaxis: IM B12 1000 loblastic anemia with icant gastric resection; mcg monthly with >60cm macrocytosis; glossitis, small intestinal bacterial ileum resected5 constipation, diarrhea; overgrowth (SIBO); vege- hand/feet paresthe- tarian diet sia; confusion, poor memory2

Vitamin D Hypocalcemia, osteo- Malabsorptive disorders, 25-(OH)D <20 ng/mL If level<20: 50,000 IU D25 malacia, osteoporosis2 small intestinal bacterial deficiency; 25-(OH)D or D3 for 12 weeks;6,7 re- overgrowth (SIBO), corti- <21-29 ng/mL insuffi- check levels and continue costeroid use ciency supplementation if still deficient. Maintenance dose of 1500-2000 IU/d D3;7 higher maintenance doses of 3000-6000 IU/d are recommended for patients on glucocorticoids, anticonvulsants, those with malabsorption,6 BMI >30, or in those with small bowel involvement.7

1 | crohnscolitisfoundation.org | January 2017 Micronutrient Signs of deficiency Risk factor for deficiency Biochemical Assessment Recommended replace- ment for deficiency

Folate (B9) Megaloblastic, macro- GI resections; patient on Low plasma or serum 1 mg folic acid daily4 cytic anemia; diarrhea, restrictive diet; use of folate (will be elevated smooth, sore tongue; sulfasalazine, methotrex- if +SIBO), elevated MCV weight loss; nervous ate, cholestyramine; ach- and homocysteine, low instability; dementia2 lorhydria; small intestinal red blood cell folate bacterial overgrowth (SIBO)

Iron Microcytic, hypochro- GI bleeding, UC, achlo- Hb 10-12 g/dL (women), In inactive IBD/normal mic anemia; tachycar- rhydria, small intestinal 11-13 g/dL (men); Serum CRP: 100 mg oral iron dai- dia; poor capillary refil, bacterial overgrowth ferritin <100 ng/mL, ly in divided doses. Addi- fatigue, sleepiness, (SIBO) transferrin saturation tional vitamin C may help headache, anorex- <20%, elevated transfer- enhance iron absorption. ia, nausea, pallor, rin receptor levels In active IBD, chronic iron impaired behavioral deficiency anemia, Hb <10 performance2 g/dL (women), <11 g/dL men: consider parenteral iron.8

Magnesium Neuromuscular hy- Chronic or severe acute Low serum magnesium 150 mg elemental Mg four perexcitability, latent diarrhea, short gut times daily4 tetany, frank seizures, arrhythmias

Pyridoxine Seborrheic dermatitis, Restrictive diets, poor Low mean plasma pyri- 50-100 mg/day5 OR (B6) microcytic anemia, oral intake, corticosteroid doxal-5-phosphate (PLP) 10 to 20 mg/day IM or IV confusion, depression, or isoniazid use concentration for 3 wk; then 2 to 5 mg/ angular stomatitis, day ORALLY for several glossitis, cheilosis2 wk.

Zinc Inadequate growth, PPI/H2 blockers, protein Low plasma or serum 50 mg elemental zinc4 for acrodermatitis en- deficiency, malabsorptive zinc 10 days. Caution copper teropathica, hypo- disorders, diarrhea, fistu- deficiency for those on gonadism, impaired lizing disease; vegetarian long term zinc supple- night vision, anorexia, diet mentation. diarrhea alterations in taste and smell, alo- pecia, impaired wound healing2

Patient education resources: The following links contain brochures and webcasts for patients on topics such as diet, nutrition, treatment, and more:

online.ccfa.org/brochures

www.ccfa.org/resources/webcasts.html

References: 1. Vagianos, K., Bector, S., McConnel, J., & Bernstein, C. N. Journal of Parenteral and Enteral Nutrition. 2007; 31(4),311-319. 2. ASPEN Core Curriculum 2012 3. NIH https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ 4. Eiden, K. A. Nutrition Issues in Gastroenterology. 2003; Series #5, 33-54. 5. Hwang, C., Ross, V., & Mahadevan, U. Inflammatory Bowel Diseases. 2012; 18(10). 1961-1981. 6. Holick, M. F., et al. Journal of Clinical Endocrinology & Metabolism. 2011; 96(7), 1911-30. 7. Basson, A. Journal of Parenteral and Enteral Nutrition. 2014; 38(4), 438-458. 8. Stein, J., & Dignass A. U. Annals of Gastroenterology. 2013; 26(2): 104–113.

The Crohn’s & Colitis Foundation acknowledges Kelly Issokson, MS, RD, CNSC, Clinical Dietitian, for the development of this resource.

This resource is supported by an independent medical educational grant from Nestlé Health Science.

2 | crohnscolitisfoundation.org | January 2017