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Kondapalli AV, Walker MD. Celiac disease and bone. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:756-764. [PMID: 36382765 PMCID: PMC10118825 DOI: 10.20945/2359-3997000000561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Celiac disease (CD) is an autoimmune disorder characterized by small intestinal inflammation triggered by gluten ingestion in genetically-predisposed individuals. A frequent extra-intestinal manifestation of CD is metabolic bone disease which contributes to an increased risk of fracture. The mechanisms underlying bone disease in CD remain incompletely understood, but multiple processes have been proposed including (1) malabsorption of calcium and vitamin D leading to secondary hyperparathyroidism and increased skeletal resorption, (2) pro-inflammatory cytokines altering the osteoprotegerin and receptor activator of nuclear kappa-B ligand ratio favoring osteoclastogenesis, (3) hypogonadism, and (4) low weight and malnutrition. Most studies show reduced bone mineral density in patients with CD. Bone microarchitecture is also deteriorated leading to reduced whole bone stiffness. Many, but not all investigations, have shown an increased risk of fracture associated with CD. The main stay of therapy for CD is maintaining a gluten-free diet. Improvement in bone mineral density with adherence to a gluten-free diet has been well-established. Bone mineral density remains lower, however, compared to controls and increased fracture risk can persist. There is no consensus on the timing of dual-energy x-ray absorptiometry for bone mineral density assessment in patients with CD. Routine screening for CD in patients with osteoporosis is not recommended. Little data are available on the use or efficacy of prescription osteoporosis therapeutics in patients with CD. Studies are needed to develop standardized guidelines for screening and treatment of metabolic bone disease in patients with CD to identify those who may need early intervention with prescription osteoporosis therapy.
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de Bruin IJA, Vranken L, Wyers CE, van der Velde RY, Trienekens TAM, Kaarsemaker S, Janzing HMJ, Wolters FL, Wouda S, Geusens PPMM, van den Bergh JPW. The Prevalence of Celiac Disease in a Fracture Liaison Service Population. Calcif Tissue Int 2020; 107:327-334. [PMID: 32725291 PMCID: PMC7497300 DOI: 10.1007/s00223-020-00725-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/08/2020] [Indexed: 12/13/2022]
Abstract
Celiac disease (CD) is a known risk factor for osteoporosis and fractures. The prevalence of CD in patients with a recent fracture is unknown. We therefore systematically screened patients at a fracture liaison service (FLS) to study the prevalence of CD. Patients with a recent fracture aged ≥ 50 years were invited to VieCuri Medical Center's FLS. In FLS attendees, bone mineral density (BMD) and laboratory evaluation for metabolic bone disorders and serological screening for CD was systematically evaluated. If serologic testing for CD was positive, duodenal biopsies were performed to confirm the diagnosis CD. Data were collected in 1042 consecutive FLS attendees. Median age was 66 years (Interquartile range (IQR) 15), 27.6% had a major and 6.9% a hip fracture, 26.4% had osteoporosis and 50.8% osteopenia. Prevalent vertebral fractures were found in 29.1%. CD was already diagnosed in two patients (0.19%), one still had a positive serology. Three other patients (0.29%) had a positive serology for CD (one with gastro-intestinal complaints). In two of them, CD was confirmed by duodenal histology (0.19%) and one refused further evaluation. The prevalence of biopsy-proven CD was therefore 0.38% (4/1042) of which 0.19% (2/1042) was newly diagnosed. The prevalence of CD in patients with a recent fracture at the FLS was 0.38% and within the range of reported prevalences in the Western-European population (0.33-1.5%). Newly diagnosed CD was only found in 0.19%. Therefore, standard screening for CD in FLS patients is not recommended.
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Affiliation(s)
- Irma J A de Bruin
- Department of Internal Medicine, VieCuri Medical Center, Tegelseweg 210, PO Box 1926, 5900 BX, Venlo, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Lisanne Vranken
- Department of Internal Medicine, VieCuri Medical Center, Tegelseweg 210, PO Box 1926, 5900 BX, Venlo, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Center, Tegelseweg 210, PO Box 1926, 5900 BX, Venlo, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Robert Y van der Velde
- Department of Internal Medicine, VieCuri Medical Center, Tegelseweg 210, PO Box 1926, 5900 BX, Venlo, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Thera A M Trienekens
- Department of Medical Microbiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Sjoerd Kaarsemaker
- Department of Orthopaedic Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Frank L Wolters
- Department of Gastro-Enterology, VieCuri Medical Center, Venlo, The Netherlands
| | - Siep Wouda
- Department of Pathology, VieCuri Medical Center, Venlo, The Netherlands
| | - Piet P M M Geusens
- Department of Internal Medicine, Subdivision Rheumatology, CAPHRI, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands
- Biomedical Research Centre, Hasselt University, Agoralaan-gebouw D, 3590, Diepenbeek, Belgium
| | - Joop P W van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Tegelseweg 210, PO Box 1926, 5900 BX, Venlo, The Netherlands.
- NUTRIM School of Nutrition and Translational Research in Metabolism, Department of Internal Medicine, Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD, Maastricht, The Netherlands.
- Biomedical Research Centre, Hasselt University, Agoralaan-gebouw D, 3590, Diepenbeek, Belgium.
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Stuckey BGA, Mahoney LA, Dragovic S, Brown SJ. Celiac disease and bone health: is there a gap in the management of postmenopausal osteoporosis? Climacteric 2020; 23:559-565. [PMID: 32960111 DOI: 10.1080/13697137.2020.1816957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Malabsorption due to celiac disease (CD) may contribute to postmenopausal osteoporosis. This study aimed to survey participants with CD regarding their bone density, fractures, and bone-preserving medications; to compare tolerance of bone-preserving medications in participants with and without CD; and to review the evidence for CD screening and osteoporosis therapies in the setting of CD. We recruited 131 participants with CD and 102 participants without CD. Of those with CD, 87% were diagnosed in adulthood and 40% had no recognized gastrointestinal symptoms. In 21% CD was diagnosed after the diagnosis of osteoporosis and in 9% after a fracture. No difference was found in the tolerability of bone medications between participants with CD and those without. Review of the literature found that, although monitoring of bone health is recommended for patients with CD, screening for CD is not generally accepted for patients with osteoporosis, although studies of the prevalence of CD in osteoporosis had incomplete ascertainment methods. There is a lack of well-conducted studies and therefore insufficient data for the efficacy and tolerability of bone medication in CD. In conclusion, both CD and menopause lead to bone loss. Identifying CD in postmenopausal women should lead to modification of osteoporosis management.
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Affiliation(s)
- B G A Stuckey
- Keogh Institute for Medical Research, Nedlands, WA, Australia.,Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Medicine, University of Western Australia, Nedlands, WA, Australia
| | - L A Mahoney
- Keogh Institute for Medical Research, Nedlands, WA, Australia
| | - S Dragovic
- Keogh Institute for Medical Research, Nedlands, WA, Australia
| | - S J Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Valero C, García MJ. Bone Metabolism in Inflammatory Bowel Disease and Celiac Disease. Clin Rev Bone Miner Metab 2019. [DOI: 10.1007/s12018-019-09269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Cronin O, Flanagan E, Dowling D. Coeliac disease in the modern era: Severity of small bowel mucosal injury at diagnosis with analysis of clinical correlates and rate of improvement on a gluten free diet. World J Gastrointest Pharmacol Ther 2018; 9:55-62. [PMID: 30568843 PMCID: PMC6288493 DOI: 10.4292/wjgpt.v9.i6.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/09/2018] [Accepted: 07/21/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the relationships between pre-diagnosis coeliac serology, duodenal histopathology, primary presenting symptoms, coeliac-related comorbidity and response to treatment in a modern cohort with new diagnosis of coeliac disease (CD).
METHODS A retrospective cohort study including 99 participants diagnosed with CD between 1999 and 2013. All patients had the following data recorded: baseline characteristics, coeliac serology, small bowel histopathology. A subset of this cohort underwent a repeat small bowel biopsy. Independent associations were assessed with logistic regression.
RESULTS The mean age at diagnosis was 43 years (Interquartile range 30-53 years) and 68% of the cohort was female. At diagnosis 49 (49%) patients had total villous blunting (MS 3c), 12 (12%) had subtotal villous blunting (MS 3b), and 29 (29%) had partial villous blunting (MS 3a). The prevalence of symptoms pre diagnosis was not related to the severity of villous blunting (P = 0.490). 87 (88%) of the cohort underwent repeat small bowel biopsy after a median of 7 mo (IQR 6-11 mo). 34 (39%) patients had biopsy results ≥ MS 3a which compared to 90 (90%) at the initial biopsy. 24 (71%) of this group reported adherence to a gluten free diet (GFD). Persistent MS ≥ 3a at repeat biopsy was not associated with symptoms (P = 0.358) or persistent positive coeliac serology (P = 0.485).
CONCLUSION Neither symptoms nor serology predict the severity of the small bowel mucosal lesion at CD diagnosis. Whilst a GFD was associated with histological improvement many patients with newly diagnosed CD had persistent mucosal damage despite many months of gluten restriction. Negative CD serology did not exclude ongoing mucosal injury.
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology, University Hospital Geelong, Geelong 3220, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent’s Hospital, Fitzroy 3065, Australia
| | - Damian Dowling
- Department of Gastroenterology, University Hospital Geelong, Geelong 3220, Australia
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Laszkowska M, Mahadev S, Sundström J, Lebwohl B, Green PHR, Michaelsson K, Ludvigsson JF. Systematic review with meta-analysis: the prevalence of coeliac disease in patients with osteoporosis. Aliment Pharmacol Ther 2018; 48:590-597. [PMID: 29984519 DOI: 10.1111/apt.14911] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/25/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Earlier studies have produced highly varying risk estimates for the prevalence of coeliac disease (CD) in osteoporosis. AIMS To investigate the prevalence of CD among individuals with osteoporosis. METHODS We conducted a systematic review of articles published in PubMed, Medline or EMBASE through May 2017 to identify studies looking at prevalence of CD in patients with osteoporosis. Search terms included "coeliac disease" combined with "fractures", "bone disease", "bone density", "densitometry", "osteoporos*", "osteomal*", "osteodys" or "dexa" or "dxa" or "skelet". Non-English papers with English-language abstracts were included. We used fixed-effects inverse variance-weighted models, and tested heterogeneity through subgroup analysis as well as through meta-regression. RESULTS We identified eight relevant studies, comprising data from 3188 individuals with osteoporosis. Of these, 59 individuals (1.9%) had CD. A weighted pooled analysis demonstrated biopsy-confirmed CD in 1.6% (95% CI = 1.1%-2.0%) of individuals with osteoporosis. The heterogeneity was moderate (I2 = 40.1%), and influenced by the underlying CD prevalence in the general population. After adding four studies (n = 814) with CD defined as positive tissue transglutaminase or endomysial antibodies, the pooled prevalence was comparable (1.6%; 95% CI = 1.2%-2.0%). CONCLUSIONS About 1 in 62 individuals with osteoporosis, or 1.6%, have biopsy-verified CD. This prevalence is comparable to that in the general population. These findings argue against routinely screening patients with osteoporosis for CD, which is contrary to current guideline recommendations. Additional studies are needed to determine the true utility of such screening programs.
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Affiliation(s)
- M Laszkowska
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - S Mahadev
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - J Sundström
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - B Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - P H R Green
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - K Michaelsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J F Ludvigsson
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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Dos Santos S, Lioté F. Osteoarticular manifestations of celiac disease and non-celiac gluten hypersensitivity. Joint Bone Spine 2017; 84:263-266. [DOI: 10.1016/j.jbspin.2016.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 12/14/2022]
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Abstract
The mode of presentation of patients with celiac disease has changed dramatically over the recent decades, with diarrheal or classic presentations becoming less common. This trend is most markedly seen in children, whose main presentations include recurrent abdominal pain, growth issues, and screening groups at risk. Among adults, presentations include diarrhea, anemia, osteoporosis, and recognition at endoscopy performed for gastroesophageal reflux disease, as well as screening. The groups most commonly screened include family members of patients with celiac disease, Down syndrome, and autoimmune diseases.
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Affiliation(s)
- Norelle Rizkalla Reilly
- Department of Pediatrics, Celiac Disease Center, Columbia University, New York, NY 10032, USA
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Lerner A, Shapira Y, Agmon-Levin N, Pacht A, Ben-Ami Shor D, López HM, Sanchez-Castanon M, Shoenfeld Y. The clinical significance of 25OH-Vitamin D status in celiac disease. Clin Rev Allergy Immunol 2012; 42:322-30. [PMID: 21210250 DOI: 10.1007/s12016-010-8237-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Reduced bone mineral density is frequently found especially in adult celiac disease (CD) and dietary guidelines favor vitamin D supplementation in adults and children with CD. Vitamin D serum levels were investigated in CD populations in order to challenge its routine supplementation. Israeli (61), Spanish (59), CD children (groups 1 and 5, respectively) were compared to children with nonspecific abdominal pain (56), their parents (84) and Spanish adult CD patients (22) (group 2, 3, 4, respectively). 25(OH)-vitamin D was checked by LIAISON chemiluminescent immunoassays. Groups 5 and 1 had the highest levels compared to groups 4 and 3 with the lowest levels. The levels in groups 1 and 2 were comparable. Concerning 25(OH)-vitamin D sera levels, only the difference between group 5 and 4 was statistically significant (30.3 ± 12.3 and 20.2 ± 10.5 ng/ml, respectively p=0.003). When vitamin D was splitted above and below 20 ng/ml level, 54.5% of Spanish adult CD had vitamin D deficiency compared to 16.9% of the local CD children (p=0.001). 29.6% of group 2 had deficient levels compared to their parents with 50% (p=0.019). In conclusion, Vitamin D sera levels negatively correlate with age. Thus, mainly adult CD population should be assessed for vitamin D levels and supplemented accordingly.
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Affiliation(s)
- Aaron Lerner
- Pediatric Gastroenterology and Nutrition Unit, Carmel Medical Center, B. Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Reilly NR, Green PHR. Epidemiology and clinical presentations of celiac disease. Semin Immunopathol 2012; 34:473-8. [PMID: 22526468 DOI: 10.1007/s00281-012-0311-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 03/26/2012] [Indexed: 12/13/2022]
Abstract
Evidence of the prevalence of celiac disease comes from serological screening studies. These have revealed that celiac disease is common, occurring in about 1 % of the population worldwide. There are some countries with higher prevalence rates such as Finland and others with lower rates, for example Germany. The disease is found in most continents and appears to be increasing. Most people with the disease are not currently diagnosed though women are diagnosed more frequently than men. The mode of presentation has changed both in children and adults with diarrhea and a malabsorption syndrome becoming less common. Abdominal pain and growth issues are major modes of presentation in children, while anemia, osteoporosis, and recognition at endoscopy performed for GERD are seen as modes of presentation in adults. Screening of at risk groups is a major mode of presentation for both adults and children.
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Affiliation(s)
- Norelle Rizkalla Reilly
- Department of Pediatrics, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Reyes García R, Jódar Gimeno E, García Martín A, Romero Muñoz M, Gómez Sáez JM, Luque Fernández I, Varsavsky M, Guadalix Iglesias S, Cano Rodriguez I, Ballesteros Pomar MD, Vidal Casariego A, Rozas Moreno P, Cortés Berdonces M, Fernández García D, Calleja Canelas A, Palma Moya M, Martínez Díaz-Guerra G, Jimenez Moleón JJ, Muñoz Torres M. [Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]. ACTA ACUST UNITED AC 2012; 59:174-96. [PMID: 22321561 DOI: 10.1016/j.endonu.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. PARTICIPANTS Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. METHODS Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. CONCLUSIONS The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.
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Abstract
The co-morbidity profile varies widely across postmenopausal women with osteoporosis, and comorbidities often adversely affect the management of osteoporosis. There is a need for detailed information on the co-morbidities that may affect the course of osteoporosis by increasing the risk of subsequent fractures or inducing multiple fractures. We consequently reviewed the literature on the most common co-morbidities in adults older than 50 years of age, with special attention to published meta-analyses. We found that osteoporosis severity was increased not only by conventional risk factors, but also by a number of conditions including inflammatory bowel and joint diseases with or without glucocorticoid therapy, breast cancer and prostate cancer treated with chemotherapy or hormone therapy, diabetes (chiefly type 1), and celiac disease. Studies suggest an adverse impact of moderate renal failure and depression, although their methodological weaknesses preclude definitive conclusions. In practice, these co-morbidities should be taken into account when evaluating the fracture risk and making treatment decisions.
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Pinkerton JV, Dalkin AC, Crowe SE, Wilson BB, Stelow EB. Treatment of postmenopausal osteoporosis in a patient with celiac disease. Nat Rev Endocrinol 2010; 6:167-71. [PMID: 20173778 DOI: 10.1038/nrendo.2009.272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A 62-year-old postmenopausal woman with a family history of breast cancer, mild gastroesophageal reflux disease, iron-deficient anemia and declining BMD was seen in a specialist center for the evaluation and management of osteoporosis. INVESTIGATIONS Analysis of tissue transglutaminase IgA, endoscopic biopsy, serial BMD scans, FRAX calculation of osteoporotic fracture risk, Gail model calculation of breast cancer risk, assessment of blood vitamin D concentration and secondary evaluation for osteoporosis. DIAGNOSIS Osteoporosis, persistent after 12 years of hormone replacement therapy, and celiac disease. MANAGEMENT The patient was initially treated for bone loss with postmenopausal hormone replacement therapy. DXA analyses showed a continued decline in BMD despite adequate replacement of calcium and vitamin D levels and withdrawal of gluten from the patient's diet. An oral bisphosphonate was recommended with plans to reassess BMD after 1 year.
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Affiliation(s)
- JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, Division of Midlife Health, University of Virginia Health System, 2955 Ivy Road, Suite 104, PO Box 801104, Charlottesville, VA 22908, USA.
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Comment identifier les sujets âgés à risque de fracture éligibles à un traitement ? ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s12612-009-0042-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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