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Canadian Journal of Gastroenterology
Volume 26 (2012), Issue 11, Pages 819-829

Evaluation and Management of Skeletal Health in Celiac Disease: Position Statement

Mona A Fouda,1 Aliya A Khan,2 Muhammad Sultan,3 Lorena P Rios,2 Karen McAssey,4 and David Armstrong2,5

1College of Medicine, King Saud University, Riyadh, Saudi Arabia
2Department of Medicine, McMaster University, Hamilton, Ontario, Canada
3Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
4Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
5Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada

Received 1 January 2012; Accepted 10 January 2012

Copyright © 2012 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


OBJECTIVE: To review the evaluation and management of skeletal health in patients with celiac disease (CD), and to make recommendations on screening, diagnosis, treatment and follow-up of low bone mineral density (BMD) in CD patients.

METHODS: A multidisciplinary team developed clinically relevant questions for review. An electronic search of the literature was conducted using the MEDLINE and EMBASE databases from 1996 to 2010. All original studies, reviews and guidelines, both pediatric and adult, were included. A document summarizing the results of the review and proposed recommendations was prepared and underwent multiple revisions until consensus was reached.

RESULTS: At diagnosis, approximately one-third of adult CD patients have osteoporosis, one-third have osteopenia and one-third have normal BMD. Children with CD have low bone mass at diagnosis. Adult and pediatric CD patients are at increased risk of fractures.

DISCUSSION: For adults, serum calcium, albumin, 25(OH) vitamin D3, parathyroid hormone and 24 h urine calcium testing should be performed at diagnosis; patients with ‘classic’ CD and those at risk for osteoporosis should undergo a dual x-ray absorptiometry scan. An abnormal baseline dual x-ray absorptiometry scan should be repeated one to two years after initiation of a gluten-free diet (GFD). For children, BMD should be assessed one year after diagnosis if GFD adherence is not strict. A GFD is the most important treatment for bone loss. Supplemental antiresorptives may be justified in those who remain at high fracture risk (eg, postmenopausal women, older men) after implementation of a GFD.

CONCLUSION: Current evidence does not support the screening of all CD patients for low BMD at diagnosis. Follow-up BMD assessment should be performed one to two years after initiation of a GFD.