Newly Diagnosed Celiacs Need Bone Density Testing

Celiac.com 04/10/2021 - It was gratifying to learn, from a recent post to the Celiac Listserv, that some celiac-savvy medical practitioners are now ordering bone density testing as soon as a patient’s serology indicates celiac disease. This emerging standard of care is well rooted in the medical and scientific literature and constitutes a reasonable and appropriate strategy for the effective care and treatment of celiac disease patients. Investigators have been recommending this approach for more than a decade(1,2) and these recommendations are particularly important given the more recent data that showing a dramatic fracture rate among celiac patients that is seven times that of controls(3,4).

Although the sensitivity of endomysium (EMA) and tissue transglutaminase (tTG) may be open to criticism, there can be little doubt that these tests are quite specific and usually reported as close to 100%. Simply put, almost everyone who has positive serological test results will be shown to have celiac disease. Thus, when an EMA or tTG test is positive for celiac disease it is very likely that the individual in question has, or soon will have, celiac disease. Although a controversial approach, some practitioners are even diagnosing celiac disease based on serology alone.  

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Researchers have long known that celiac disease is associated with significant bone demineralization and increased risk of fractures(5). Relevant research also shows that therapeutic intervention in celiac patients can require a very different approach than with non-celiac patients(6-7) and there is considerable variation from one celiac patient to the next(1) which practitioners must also consider.    

Suspected causes of the increased bone disease and fracture risk include: reduced intestinal absorption area and compromised active transport of calcium across the intestinal barrier3; hyperparathyroidism, possibly as the result of cross reaction of endomysium antibodies with parathyroid tissues(8); autoimmune hyperthyroid disease, which is frequently found in association with celiac disease(9); excessive mineral release from the bones and excretion(3); vitamin D deficiency(10); along with a host of other celiac-associated possibilities. Each or many of the above factors are likely contributors to the unique needs of every newly diagnosed celiac patient.  

Even when bone density testing reveals metabolic bone disease, it does not reveal the exact nature of the underlying problem(3) and celiac disease patients with bone mineral losses often can not be predicted clinically(1) so testing is the only rational option. While a strict gluten-free diet will usually have a positive impact on bone density, that improvement falls far short of control values(11). Bone density values and trends will provide assistance in determining individual fracture risk, which is an important clinical consideration(2).  

Every person, regardless of their celiac disease diagnosis, is unique. It is especially important that each one should have early testing to determine their bone mineral status at diagnosis because of the very strong association between celiac disease and bone disease.  Such test results enable health care providers to monitor their celiac patients’ bone health and fracture risk. Simply put, if we can not see where we started from, how can we tell how far we have come or whether we are moving in the right direction?  Early bone density testing is the first step in therapeutic intervention. In many cases, coupled with follow-up testing, it will be the only intervention needed. 

In other cases, however, bone density testing will be the first step in a lengthy therapeutic process that may involve several changes in treatment as the individual progresses. Some patients may require magnesium supplementation as part of a therapeutic intervention for parathyroid disease(6). Others may need treatment for autoimmune thyroid disease which afflicts more than 12.9% of newly diagnosed celiac patients(12). Most celiac patients have been shown to have low vitamin D status(10) which, depending on a variety of factors, may indicate a need for vitamin D supplementation. Still others may require pharmacological interventions. 

Alert practitioners will, in keeping with the literature, order bone density testing. Abnormal results should identify concurrent bone disease and alert the practitioner to the need for further testing to determine the exact nature of the pathology/pathologies that may be at work. Regardless of the particular cause of bone disease or abnormality, bone density testing is the very first step in each of these interventions. Follow-up bone density testing will usually provide meaningful information to direct treatment and is especially useful when juxtaposed with initial test results. 

There can be little doubt that bone density testing is appropriate for newly diagnosed celiac disease patients. This practice is strongly advocated in the medical and scientific literature, and promises to mitigate the sometimes ghastly consequences of bone disease, demineralization, and degeneration that are too often found in association with celiac disease. Ultimately, such testing will not only improve quality of life for celiac patients, but in combination with appropriate supplementation, dietary, and pharmacological practices, this testing will save health care dollars through reduced needs for acute care. 

For these reasons, I was surprised to read that the insurance company of the person who posted that message to the celiac listserv had refused to pay for the bone density testing ordered by her health care practitioner on the basis of positive celiac serology. In the early days of endomysium and tissue transglutaminase testing, some insurance companies also failed to see that serological testing would one day save substantial sums by reducing the number of endoscopic biopsies required for a celiac diagnosis. My own diagnosis required three endoscopic biopsies. Similarly, it appears that at least one insurance company is overlooking the savings from acute care that they will accrue from the emerging standard of care in which bone density testing is ordered for all patients with positive celiac serology tests. One can only hope that they will soon recognize the real cash value such testing offers to health insurance providers. 

References: 
1.    Walters JR, Banks LM, Butcher GP, Fowler CR. Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated celiac disease.  Gut. 1995 Aug;37(2):220-4.
2.    Pistorius LR, Sweidan WH, Purdie DW, Steel SA, Howey S, Bennett JR, Sutton DR. Coeliac disease and bone mineral density in adult female patients. Gut. 1995 Nov;37(5):639-42.
3.    Fickling WE, McFarlane XA, Bhalla AK, Robertson DAF. The clinical impact of metabolic bone disease in coeliac disease. Postgrad Med J. 2001; 77:33-36
4.    Vitoria JC, Arrieta A, Arranz C, Ayesta A, Sojo A, Maruri N, Garcia-Masdevall MD.  Antibodies to gliadin, endomysium, and tissue transglutaminase for the diagnosis of celiac disease. J Pediatr Gastroenterol Nutr. 1999 Nov;29(5):571-4.
5.    Marsh MN. Bone disease and gluten sensitivity: time to act, to treat, and to prevent. Am J Gastroenterol. 1994 Dec;89(12):2105-7.
6.    Rude RK, Olerich M. Magnesium deficiency: possible role in osteoporosis associated with gluten-sensitive enteropathy. Osteoporos Int. 1996;6(6):453-61.
7.    Hoggan R.
8.    Kumar V, Valeski JE, Wortsman J. Celiac disease and hypoparathyroidism: cross-reaction of endomysial antibodies with parathyroid tissue. Clin Diagn Lab Immunol. 1996 Mar;3(2):143-6.
9.    Kisakol G, Kaya A, Gonen S, Tunc R. Bone and Calcium Metabolism in Subclinical Autoimmune Hyperthyroidism and Hypothyroidism. Endocrine Journal Vol. 50 (2003) , No. 6 657-661
10.    .Kemppainen T, Kröger H, Janatuinen E, Arnala I, Kosma VM, Pikkarainen P, Julkunen R, Jurvelin J, Alhava E, Uusitupa M. Osteoporosis in adult patients with celiac disease. Bone. 1999 Mar;24(3):249-55. 
11.    McFarlane XA, Bhalla AK, Robertson DA.Effect of a gluten free diet on osteopenia in adults with newly diagnosed coeliac disease. Gut. 1996 Aug;39(2):180-4.
12.    Sategna-Guidetti C, Volta U, Ciacci C, Usai P, Carlino A, De Franceschi L, Camera A, Pelli A, Brossa C.  Prevalence of thyroid disorders in untreated adult celiac disease patients and effect of gluten withdrawal: an Italian multicenter study. Am J Gastroenterol. 2001 Mar;96(3):751-7.