Bone Health in Celiac Disease. Partha S. Sinha MD, PhD October 29 th, 2017
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1 Bone Health in Celiac Disease Partha S. Sinha MD, PhD October 29 th, 2017
2 No Disclosures
3 Objectives Recognize the mechanisms by which celiac disease can affect bone health Review what diagnostic tests are useful Understand the role of nutrition and proper supplementation Gain awareness when pharmacologic or other intervention may be needed
4 Celiac Disease Intestinal disorder characterized by auotimmune reaction to gliadin fraction of gluten Associated with human leucoctye antigen (HLA) genes Multiple non intestinal manifestations Type 1 Diabetes Thyroiditis/Hypothyroidism Metabolic bone disease
5 Prevalance of bone disease in celiac Low bone density is more prevalent Kemppainen, Bone 1999
6 Celiac Disease and Fracture Risk Fracture risk appears modestly higher West, Gastroenterology 2003
7 Why does celiac disease affect bone? Calcium Vitamin D? Inflammation Image from: Dickey, Scand J Gastroenterol 2011
8 Calcium and Bone Avg human with ~ 1 kg of calcium 99% in bone Essential for bone strength Image from: Poole, PLoS One 2011 Emkey, Endocrinol Metab Clin N Am 2012
9 Osteomalacia Calcium deficiency can lead to bone demineralization A distinct mechanism from osteoporosis Image from: Jones, J Musculoskel Med 2009 Emkey, Endocrinol Metab Clin N Am 2012
10 Calcium Absorption Primarily in intestine duodenum Vitamin D has essential role Khanal, Ann Rev Nutr 2008 Image from: The American Heritage Medical Dictionary. 2007
11 Calcium Homeostasis PTH PTH Vit D Ca 2+ Images from: The American Heritage Medical Dictionary Potts, Harrison s Principles of Internal Medicine 2014
12 Calcium Malabsorption in Celiac Disease Villous atrophy less surface area for absorption Intestinal Inflammation Loss of calcium transport proteins Impaired Vitamin D absorption Particularly if fat malabsorbed Krupa-Kozak, Nutrition 2014
13 Celiac Disease Villous Atrophy Normal Celiac Kambol, Clin Trans Gastroenterol, 2014
14 Calcium Malabsorption in Celiac Disease PTH Ca 2+ Vit D Potts, Harrison s Principles of Internal Medicine 2014 Krupa-Kozak, Nutrition 2014 Ca 2+
15 Secondary Hyperparathyroidism in Celiac Disease Parathyroid gland key regulator of calcium balance In response to decreased calcium and vitamin D absorption, parathyroid glands react by removing calcium from bone Khanal, Ann Rev Nutr 2008 Potts, Harrison s Principles of Internal Medicine 2014
16 Calcium Malabsorption in Celiac Disease PTH Ca 2+ Vit D Direct Inflammatory Effects? Potts, Harrison s Principles of Internal Medicine 2014 Krupa-Kozak, Nutrition 2014 Ca 2+
17 How to assess risk to bone health Blood tests Bone densitometry Low impact fractures -this warrants more urgent attention
18 Blood Tests Creatinine (kidney function) Calcium Vitamin D 25 OH Parathyroid hormone (PTH) Image from: mayomedicallaboratories.com
19 Serum Calcium Level Low serum calcium suggests deficiency High serum calcium needs further testing Normal serum calcium can be deceptive Ca 2+
20 24 Hour Urine Calcium More accurate reflection of calcium asborption Creatinine should be tested on same sample Image from: The Office 2010
21 Bone Densitometry (BMD) Surrogate for bone strength T score -1 to -2.5 osteopenia T score < -2.5 osteoporosis Spine and hip usually analyzed Melton, J Bone Miner Res 1992
22 When to get a BMD Consider doing after allowing for some time to treat the celiac disease and getting adequate calcium and vitamin D May do earlier in situations where osteoporosis medication may be needed Post menopausal -on glucocorticoids (steroids) High risk of fracture (type I diabetes, family history of hip fracture)
23 Treating Celiac Bone Disease Gluten Free Diet Calcium through diet and/or supplement Vitamin D Osteoporosis medications
24 Gluten Free Diet Improves BMD in children Recommended but may not be enough for the bone loss in adults Bianchi, Calcif Tissue Int 2002
25 Optimizing Calcium Intake 1200 mg calcium is RDA May be higher requirement in celiac disease Feasible to get via diet Yogurt: mg Broccoli mg Milk: mg Tofu mg
26 Calcium Supplements Fat Malabsorption (aka steatorrhea) Lactose Intolerance Diet too difficult
27 Calcium Supplements Calcium carbonate TUMS Caltrate -more common Not absorbed when on heartburn medication 500 mg Calcium Carbonate PIll Calcium Citrate Citracal 400 mg Calcium Citrate PIll
28 Assessing Calcium Intake Serum calcium (can be deceptive if normal) Parathyroid hormone level 24 hour urine calcium
29 Vitamin D and Bone Health Integral to calcium absorption and homeostasis May have direct role in bone formation and regneration Goltzman, Ann NY Acad Sci 2011 Lips, Best Pract Res Clin Endocr Metab 2011
30 Vitamin D More difficult to get via diet 400 to 2000 units vitamin D (presuming limited sun exposure) May need more if steatorhea/severe GI symptoms units vitamin D National Osteoporosis Foundation, 2013 Image from: webmd.com
31 Assessing Vitamin D Intake Replacement guided by serum levels Goal level > 30, though may be acceptable
32 When Osteoporosis Medications If BMD T scores persistently below 2.5 Fragility fracture Post menopausal women Glucocorticoid Use Prednisone, solumedrol are Needed Other risk factors Family History Type I Diabetes Lee, Yonsei J Med 2011
33 Oral Bisphosphonates Alendronate (Fosamax) 70 mg weekly Risedronate (Actonel) 35 mg weekly or 150 mg monthly Ibandronate (Boniva) 150 mg monthly Rosen, UptoDate, 2014
34 If oral medication not tolerated or severe osteoporosis Zoledronate (Reclast) 5 mg yearly Denosumab (Prolia) 60 mg every 6 months No adjustment for renal insufficency Teriparatide (Forteo) 20 mcg SC daily Only anabolic agent Rosen, UptoDate, 2014
35 Osteoporosis Medications Ideally, calcium and vitamin intake should be optimized before starting these medications Possible risk of hypocalcemia with more potent medications Rosen, UptoDate, 2014
36 Conclusions
37 Celiac Disease Has Significant Impact on Bone Health PTH Ca 2+ Vit D Ca 2+ INFLAMMATION
38 Medical Testing Can Guide Maintenance of Bone Health Creatinine (kidney function) Calcium Vitamin D 25 OH Parathyroid hormone (PTH) 24 hour urine calcium Bone densitometry
39 Diet and supplements can make an May be higher requirement in celiac disease Feasible to get via diet, but pills can be effective if needed impact
40 Osteoporosis Medications May Sometimes Be Warranted Ultimate goal is to avoid fractures
41 Acknowledgments Harold Rosen, MD Alan Malabanan, MD Henry Kronenberg, MD Melinda Dennis, MS, RD, LDN National Celiac Association
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