Osteoporosis and Celiac Disease
Abstract & Commentary
With Comment by Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California and Associate Editor, Internal Medicine Alert.
Synopsis: Celiac disease was found in 3.4% of patients with osteoporosis, compared to 0.2% without. Treatment with a gluten-free diet improved bone density scores. This study postulates that this prevalence justifies serologic screening for celiac disease in all patients with osteoporosis.
Source: Stenson WF, et al. Arch Intern Med. 2005;165: 393-399.
The Washington University of School of Medicine Bone Health Clinic solicited all patients over a 2-year period for blood testing for celiac disease, resulting in 266 with osteoporosis and 574 without. Exclusions were made for corticosteroid use, malignancy, or known celiac disease, but not for cigarette smoking or other lifestyle factors. Bone density was established using dual-energy X-Ray absorptiometry and the lowest T score of the hip, spine, or femoral neck. If either of the antibody tests for celiac disease (IgA anti-TTG, or IgA anti-EMA) were positive, patients were offered intestinal biopsy at 8 random sites in the distal duodenum and proximal jejunum.
Nine of the subsequent biopsy-positive celiac disease patients were osteoporotic (3.4% of the 266 with osteoporosis), and only one positive was in the non-osteoporotic group (0.2% of those without). All of the biopsy-positive cases had both anti-TTG and anti-EMA blood tests positive, and 5 other biopsies performed on cases with only one of these antibody tests positive were negative for celiac disease. Antibody tests for the wheat protein gliadin were not correlated with disease, and found frequently in about 20% of all participants. Most celiac disease patients also had biochemically evident secondary hyperparathyroidism with 25-hydroxy vitamin D deficiency.
Eight of the osteoporotic individuals with celiac disease were able to maintain a gluten-free diet for 1 year along with medical therapy for osteoporosis, and 6 of them had more improvement in their bone density T scores greater than expected for those receiving standard osteoporosis therapy. They also had improvement in diarrhea, weight loss, and alkaline phosphatase levels.
Comment
Screening blood tests are now available for celiac disease using standardized, quantitative serology for IgA antitissue transglutaminase (anti-TTG) or IgA antiendomysial antibody (anti-EMA), since the intestinal enteropathy results from immune responses to gliadin, a component of wheat proteins. In this study, intestinal biopsy confirmed the positive blood tests in 10 of 16 cases (2 other positive blood tests declined the biopsy).
Both tests returning positive is likely to be sufficient for diagnosis unless the individual if IgA deficient (false negatives estimated to be 2.8-8%).
An accompanying editorial points to other articles which have not shown such strong associations between celiac disease and increased fracture risk, and suggests that the most screening benefit would actually be found in testing high-risk white women under the age of 18, in order to maximize the bone mass that is determined in youth.1 At the present cost of $80-120 for each screening test, they project that population costs for screening would be $43,000 to prevent a single fracture, which is similar to the cost of mammography to detect breast cancer in asymptomatic individuals. Their conclusion is that it is impossible to make clear recommendations for widespread celiac disease screening at this time.
Nonetheless, this new information certainly propels us to test more frequently for celiac disease and intervene more aggressively when it is found; a review of our current understanding of this disease has just been published.2 Until more is known, our best hope for fracture prevention still remains to encourage weight-bearing exercise, adequate calcium and vitamin D intake, and early treatment for osteopenia.
References
1. Buchman AL. Arch Intern Med. 2005:165:370-371.
2. Alaedini A, et al. Ann Intern Med. 2005;142:289-298.
Celiac disease was found in 3.4% of patients with osteoporosis, compared to 0.2% without. Treatment with a gluten-free diet improved bone density scores. This study postulates that this prevalence justifies serologic screening for celiac disease in all patients with osteoporosis.
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