Systematic Review With Meta-analysis

The Prevalence of Coeliac Disease in Patients With Osteoporosis

M. Laszkowska; S. Mahadev; J. Sundström; B. Lebwohl; P. H. R. Green; K. Michaelsson; J. F. Ludvigsson


Aliment Pharmacol Ther. 2018;48(6):590-597. 

In This Article

Abstract and Introduction


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 (I 2 = 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.


Coeliac disease (CD) is a life-long immune-mediated disease that is triggered by exposure to gluten in genetically sensitive individuals.[1] It is characterised by small intestinal inflammation and villous atrophy (VA) in the small intestine.[2] Individuals with CD are at increased risk of a number of complications including other gastrointestinal diseases,[3,4] as well as extraintestinal disease, malignancy[5] and death.[6]

Small intestinal VA leads to malabsorption of nutrients, and CD patients may present with not only weight loss and diarrhoea, but also fractures. A recent meta-analysis reported that CD patients are at a 30% increased risk of any fracture and at a 69% increased risk of hip fracture.[7] Furthermore, another recent meta-analysis found that patients with CD had an increased risk of osteoporosis (OR 2.73, CI 1.86–3.99),[8] as did one large screening study.[9] These studies did not, however, examine the risk of CD in patients first diagnosed with osteoporosis. Such information is crucial for clinicians as this will guide whether they should screen individuals with osteoporosis for CD. The reported prevalence of CD in individuals with osteoporosis has varied between 0%[10] and 33%.[11] While these two studies[10,11] represent extremes, there is also variability among the two largest studies so far,[12,13] where the CD prevalence in individuals with osteoporosis varied between 1.1% and 1.9%.

The primary aim of this systematic review was to examine the prevalence of CD in individuals with osteoporosis. A secondary aim was to investigate if the prevalence of CD varies between subgroups of individuals with osteoporosis.