In summary, all gastroenterologists treating patients with IBD should appreciate that no corticosteroid dose can be considered safe with respect to bone mineral metabolism. Recent data suggest that routine use of budesonide lessens the probability of altering bone mineral density in patients with IBD (Matrix study) ; hence, budesonide should be considered in place of corticosteroids. Several other options are available to prevent corticosteroid-induced osteoporosis. Achieving peak bone mass during childhood and adolescence is essential to promote bone development in accordance with the recommended daily allowance of calcium and vitamin D supplementation. Children with CD are often faced with active disease requiring corticosteroid therapy, which affects their nutrition, growth, and ability to perform daily exercise. In these patients, early recognition and diagnosis of IBD is imperative. Moreover, therapy should be initiated in a manner that facilitates the most rapid induction of disease remission with the least possible corticosteroid requirements. In patients with steroid-dependent disease, early use of immunosuppressive therapy (azathioprine, 6-mercaptopurine, or methotrexate) is important to limit the cumulative exposure to corticosteroids. Patients with recalcitrant disease should have their treatment escalated to biologic therapies, including infliximab, and possibly surgery as a bridge to achieve disease remission, preferably prior to the onset of puberty. Furthermore, pediatric gastroenterologists should be sensitive to the time of onset of puberty. As a general rule, children tend to follow the developmental patterns of their biologic parents; that information can be used as a guide to tailor medical therapy in patients with moderate to severe disease with the aim of avoiding corticosteroid use during puberty. Therapy should be tailored to achieve rapid disease remission.
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