Osteosarcopenia in autoimmune cholestatic liver diseases: Causes, management, and challenges

Table 1 Prevalence of osteoporosis and fractures according to the severity and stage of primary biliary cholangitis

Ref.	N of patients	Age (yr) mean	Female (%)	Diagnosis	Osteoporosis (%)	Vertebral fractures (%)	Peripheral fractures (%)	Overall fractures (%)	Cirrhosis (%)
Guañabens et al[114]	38	51	100	DPA	45	13	NR	13	94
Parés et al[68]	61	54	100	DXA	21	10	10	13	26
Guañabens et al[65]	142	54	100	DXA	31	14	11	14	26
Guichelaar et al[39]	156	53	86	DXA	44	22	NR	22	100
Guañabens et al[62]	185	56	100	DXA	32	11	12	21	23
Solaymani-Dodaran et al[115]	930	NR	88	NR	NR	NR	7.4	14.7	31

NR: Not reported; DXA: Dual-energy X-ray absorptiometry; DPA: Dual-photon absorptiometry.

Table 2 General expert recommendations for management of osteosarcopenia in patients with cholestatic liver diseases

Risk for osteoporosis should be considered in all patients with cholestatic liver diseases
DXA should be considered to assess BMD at presentation and at follow-up where indicated	T-score > -1.5 - > repeat in 2-3 yr
	Osteopenia, T-score ≤ -1.5 but > -2.5, or presence of risk factors - > repeat in 1-2 yr
	Osteoporosis, T score ≤ -2.5, or pathological fractures with normal BMD - > repeat in one year
VFs should be investigated at presentation with lateral spine X-rays radiograph in all patients with cholestatic liver diseases
Alcohol and smoking cessation in addition to increasing aerobic exercise and practicing routine weight-bearing exercises are highly recommended in all patients with cholestatic liver diseases
Consider including supplements of 25-(OH)-vitamin D (800 IU daily) and calcium (1000–1500 mg daily) in patients with cholestatic liver disease and osteopenia or osteoporosis
Consider utilizing bisphosphonates in patients with osteoporosis and patients with VFs, regardless of underlying disease and BMD values
For patients with PBC, denosumab might have a beneficial role both for osteoporosis treatment and for PBC but data are scarce, and recommendation cannot be made yet
Consider evaluating sarcopenia by cross-sectional imaging when strong clinical suspicion is present in all patients with cholestatic liver diseases
Consider exercise programs and adequate nutritional and caloric intake in all patients with sarcopenia and cholestatic liver diseases

DXA: Dual-energy X-ray absorptiometry; BMD: Bone mineral density; VFs: Vertebral fractures; PBC: Primary biliary cholangitis.