A Remarkable Increase in Bone Mineral Density in Celiac Disease
Presentation Number: SUN 311
Date of Presentation: April 2nd, 2017
Karina Szczepanczyk*1, Hooman Saberinia2 and Faryal Sardar Mirza2
1University of CT Health Center, Farmington, CT, 2University of Connecticut Health Center, Farmington, CT
Introduction: Patients with active celiac disease (CD) are more likely to have osteoporosis and have an increased risk of fractures (1-3) There is a general consensus in the literature about adherence to a gluten-free diet (GFD) improving bone mass, with some studies showing significant improvement in bone mineral density (BMD) and DXA T-score ranging from 2.5%-3.7% (4-6). However, less is known about the concomitant use of bisphosphonates in this population. Here, we report a case of celiac disease with progressively declining BMD, with remarkable improvement after one year of GFD and oral bisphosphonate therapy. No other cases have been reported on the benefits of this treatment strategy.
Clinical case: A 44-year old premenopausal female with history of bronchiectasis had a low screening bone density at the ankle at 39 years of age. Confirmatory testing with central dual-energy X-ray absorptiometry established the diagnosis of osteoporosis of the spine (0.885 g/cm2, T-score -2.5) and hips (0.705 g/cm2, T-score -2.5). She was managed conservatively with supplemental calcium and vitamin D by her primary care MD. Bone density stabilized over next 3 years. Celiac screen was positive at the time but a gluten free diet was not strictly implemented. 2 years later a repeat BMD scan revealed 7.6% decrease in bone density at the vertebral spine (T-score -3) and 5.8% decline at the total hip (T-score -2.7) and she was referred to us for further evaluation. She had never been on long term steroids. Laboratory evaluation revealed a high bone turnover with an elevated urine NTx of 66 NTX units and PTH of 162 pg/mL (10-65 pg/mL), repeat testing 2 months later at 98 pg/ml. A low calcium level of 8.8 mg/dL (normal range 8.9-10.1 mg/dL), normal vitamin D levels (on vit D 2000 units a day), and low urine calcium levels suggested secondary hyperparathyroidism. 1,25 dihydroxyvitamin D was elevated at 82 pg/ml. Tissue glutaminase antibody IGA was elevated at >100 units, although she denied any diarrhea or bloating. Duodenal biopsy revealed villous blunting and focal intraepithelial lymphocytic infiltrates compatible with active celiac disease. She was started on a GFD and alendronate was later added in view of low bone density and high bone turnover. Labs in 6 months showed normalization of calcium and PTH levels (34 pg/ml). Bone density performed one year later revealed a remarkable 14.1% increase at the level of the lumbar spine (T-score -2.1) and 8.9% increase at the total hip (T-score -2.3).
Discussion: Osteoporosis is a known complication of celiac disease and should be addressed soon after diagnosis. Although the role of a GFD in improvement of bone density has been studied in this population, this is the first case report that implemented a GFD and concomitant use of bisphosphonates. The remarkable increase in BMD suggests a cumulative benefit of this strategy that is greater than using either of these interventions alone.
Nothing to Disclose: KS, HS, FSM