Potential risk factors for osteonecrosis: Several possible risk factors for osteonecrosis were independently evaluated. These are schematically shown in Figure 1. Risk factors included use of corticosteroids, use of parenteral nutrition (all administered solutions included lipid emulsions), or concomitant corticosteroid and parenteral nutrition. In addition, because nutrient absorption may be a factor in the pathogenesis of bone disease in Crohn’s disease, the frequency of small bowel resection in this group of 877 patients was also considered.
A total of 483 patients with Crohn’s disease (55.1%) were treated with some form of corticosteroid during their management, usually oral prednisone, for at least one treatment course, most often as part of their pharmacological management. For men with Crohn’s disease, 187 of 385 (48.6%) received at least one course of corticosteroids. For prednisone, the usual initial dose given was 20 to 40 mg daily, and this dose was tapered over a period of four to 10 weeks. Occasionally, patients required longer periods of lower doses of 5 to 10 mg daily before the oral prednisone could be discontinued. Hospitalized patients treated with intravenous cortico- steroids usually received hydrocortisone 200 mg daily (equivalent to about 40 mg of prednisone).
This was usually tapered in the hospital to approximately 100 mg daily before conversion to an oral corticosteroid. Fewer than 1% of all corticosteroid-treated patients received budesonide as a form of corticosteroid therapy during their treatment.
A total of196 patients (22.4%) received parenteral nutrition during hospitalization, either for primary therapy to provide therapeutic ‘bowel rest’, sometimes with other forms of pharmacological management, including corticosteroids, or for direct nutritional support, usually in the perioperative period. Of these 196 patients who received parenteral nutrition, 125 also received corticosteroids at some time during their disease course, often concomitantly with this nutritional support therapy. Of the 385 men, 85 received a course of parenteral nutrition and 63 received both corticosteroids and parenteral nutrition.
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A total of 311 patients (35.5%) required hospitalization for one or more small intestinal resections for their Crohn’s disease, usually because of obstructing symptoms. No patient who had a small bowel resection developed osteonecrosis. Of the 385 men, 137 (35.5%) had a small bowel resection.