What are the College of Family Physicians of Canada recommendations for managing bone health in adult and pediatric patients with celiac disease?

Updated: Oct 10, 2018
  • Author: Stephan U Goebel, MD; Chief Editor: BS Anand, MD  more...
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Answer

The 2018 College of Family Physicians of Canada released their recommendations for managing bone health in adult and pediatric patients with celiac disease, including the following [55] :

Adults

  • Adults with malabsorption should undergo BMD testing at diagnosis as well as be evaluated for their levels of calcium, phosphate, and vitamin D. If the BMD results are normal at diagnosis, consider follow-up testing 2-3 years after starting a gluten-free diet.

  • At diagnosis with celiac disease, patients should be provided with counseling by dieticians with expertise not only in gluten-free diets but also in nutritional requirements for restoration of bone health. Optimal daily intake of recommended levels of calcium and vitamin should be from dietary sources (especially dairy) whenever possible.

  • Encourage patients to participate in weight-bearing exercises, limit alcohol intake, and avoid tobacco use.

  • Adults without malabsorption but who are at high risk of bone disease should also undergo BMD testing at diagnosis with celiac disease.

  • Those with subclinical or asymptomatic celiac disease should have a gluten-free diet and adequate calcium and vitamin D supplementation. After 1 year of such treatment, these patients should undergo BMD evaluation before further management.

  • Osteoporotic/osteopenic patients at diagnosis with celieac disease or individuals nonadherent to a gluten-free diet should have repeat BMD testing after 1-2 years on a gluten-free diet with calcium and vitamin D supplementation. An gluten-free expert dietician should routinely assess patients for adherence to this diet. 

Children and adolescents

  • Routine BMD is unnecessary in pediatric patients diagnosed with celiac disease at a young age. At diagnosis, management with adherence to a gluten-free diet as well as monitoring of growth and vitamin D levels are sufficient.

  • Consider BMD testing in children diagnosed with celiac disease who present with growth failure, severe malabsorption, prolonged diagnostic delay, or clinical evidence of bone disease. Repeat BMD testing every 1-2 years until the findings are normal, particularly in teenaged patients.

  • Children with inadequate sun exposure and insufficient dietary intake of calcium and vitamin D at diagnosis should undergo vitamin D studies and receive vitamin D supplementation, as needed. As with adult patients, provide counseling regarding adequate dietary intake of calcium and vitamin D, as well as weight-bearing exercises.

The College of Family Physicians of Canada also noted that "the role of antiresorptive medications in reducing the risk of fractures in patients with CD also remains unclear," and that the decision regarding use of hormone replacement therapy in perimenopausal women be individualized. [55] Therefore, clinicians should follow the guidelines from major gastroenterology, endocrinology, and dietetic associations. In patients adhering to 1-2 years of a gluten-free diet with adequate calcium and vitamin D supplementation who show persistent signs of osteoporosis, consider adding specific osteoactive therapies. [55]


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