Transcript PCOS Guidelines - Keogh Institute For Medical Research

Coeliac disease –
a silent cause of bone loss in midlife
Bronwyn Stuckey1,2,3, Joanna Wagner1, Jocelyn Tan1, Smilja Dragovic1, Lee Ann Mahoney1
1. Keogh Institute for Medical Research;
2. Department of Endocrinology and Diabetes Sir Charles Gairdner Hospital;
3. School of Medicine and Pharmacology University of Western Australia
Keogh Institute for
Medical Research
Coeliac disease
• Chronic intestinal
disorder
• Cause by immune
reaction to the gliadin
fraction of gluten found
in wheat, rye, barley
• Cases villous atrophy
from duodenum to
distal ileum
Keogh Institute for
Medical Research
Coeliac disease presentations
In the past = typical
 steatorrhoea
 weight loss
 Anaemia
Now = atypical
 dyspepsia
 iron deficiency
 infertility
 osteoporosis
Keogh Institute for
Medical Research
Aims
• Assess the prevalence of bone density assessment in
adults with coeliac disease
• Document the choices of bone preserving therapy
used in patients with coeliac disease
• Assess the prevalence of side effects of bone
preserving therapy in general in people with coeliac
disease compared with controls
Keogh Institute for
Medical Research
Why did we do this study?
Prompted by a case series of 4 patients with unmasking or
deterioration of CD with oral alendronate
Torrential diarrhoea 3-4 months after starting oral bisphosphonate
Stuckey and Sallie Osteoporosis International 2015
Keogh Institute for
Medical Research
Methods
Participants were recruited
through the Coeliac Society
of WA via their monthly
newsletter
Participants completed an on-line
questionnaire (Survey
Monkey) or given the option
to complete a paper version
Informed consent was given online or, in the case of paper
questionnaire, by signed
consent.
The study was approved by the
SCGH Human Research Ethics
Committee
Keogh Institute for
Medical Research
Age of participants with coeliac disease
Participants = 80
4.5
4
3.5
3
2.5
Participants
2
1.5
1
0.5
0
<20
29
39
49
59
69
79
89
Keogh Institute for
Medical Research
Age at diagnosis of coeliac disease
30.0%
25.0%
20.0%
90% diagnosed in adulthood
36% after the age of 50 years
15.0%
10.0%
5.0%
0.0%
Less than 10
years old
<10y
10-19 years old 20-29 years old 30-39 years old 40-49 years old 50-59 years old 60 years or older Other (please
specify)
10-19 20-29
30-39 40-49 50-59
years
>60
Keogh Institute for
Medical Research
Symptoms recognised before diagnosis
42% of respondents reported no recognisable symptoms before the diagnosis
Bloating
Fatigue
Diarrhoea
Abdominal pain
Constipation
Weight loss
Anaemia
Indigestion
Osteoporosis
Fracture
Percentage
0
20
40
60
80
100
Keogh Institute for
Medical Research
Symptoms recognised after diagnosis
Fracture
Osteoporosis
Anaemia
Fatigue
Bloating
Indigestion
Constipation
Diarrhoea
Abdominal pain
Weight gain
Weight loss
Percentage
0
10
20
30
40
50
60
70
80
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Medical Research
90
Participants with coeliac disease bone density and fractures
Age
<20
years
20-30
30-40
40-50
50-60
>60
3
1
3
13
Have you had a bone density performed?
No
BMD
2
5
4
2
Have you had a fracture (minimal trauma)?
Yes
2
2
2
2
Keogh Institute for
Medical Research
32% reported minimal trauma fracture
number
Wrist
Arm
Fingers or toes
Tibia or fibula
number
Ribs
Vertebra
Femur
Shoulder
0
2
4
6
8
10
Keogh Institute for
Medical Research
Use and tolerability of bone preserving medications
35
30
25
20
number
S/E
15
stopped
10
5
0
Calcium
Vitamin D
Alendronate Risedronate Zoledronate
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Medical Research
Use and tolerability of bone preserving medications
35
30
25
20
15
10
5
number
S/E
stopped
0
Keogh Institute for
Medical Research
Comparison of reported side effects –
HRT v alendronate
50
45
40
35
30
25
20
15
10
5
0
Alendronate n = 12
Oral HRT n=13
Patch HRT n=14
%
Keogh Institute for
Medical Research
Tolerability – coeliac disease v controls
Numbers & % S/E
70
60
50
40
30
20
10
0
Calcium
Vitamin D
Alendronate
Risedronate
Zoledronate
CD n=
% S/E
32
28
31
6
12
58
3
0
6
50
No CD n=
% S/E2
42
19
43
9
31
39
21
33
3
67
Keogh Institute for
Medical Research
Tolerability – coeliac disease v controls
Numbers & % S/E
70
60
50
40
30
20
10
0
Calcium
Vitamin D
Alendronate
Risedronate
Zoledronate
CD n=
% S/E
32
28
31
6
12
58
3
0
6
50
No CD n=
% S/E2
42
19
43
9
31
39
21
33
3
67
Keogh Institute for
Medical Research
Comments about coeliac disease and bone from participants
• 44% of participants believed that CD had an
impact on management of bone health
– Side effects from medication
– Not absorbing calcium
– Not absorbing nutrients
– Low dairy diet
– Too tired to exercise
Keogh Institute for
Medical Research
Comments about coeliac disease and bone from participants
•
“Poor bone density led to diagnosis of celiac disease”
•
“Since going on a gluten free diet my bone density has improved except in my arms. I don't have
my thyroid glands and believe this affects the extremities of your body “
•
“It is difficult to balance diet “
•
“Undiagnosed coeliac disease for a number of years resulting in poor calcium absorption”
•
“I believe my asymptomatic and therefore undiagnosed coeliac disease led to my osteopenia (at
age 26)”
•
“I keep hearing from the internet it is something I should be concerned about but my Dr has never
mentioned it”
•
“I was absolutely horrified to find I had quite bad osteoporosis at 51. I only had a bone scan
because that was included in the info I got when I joined Coeliac WA the month before, and I
asked my GP to organise it because I had fractured my wrist 6 months earlier”
Keogh Institute for
Medical Research
Conclusions
• Coeliac disease should be excluded as
contributing to osteoporosis in the
postmenopausal woman, regardless of the
absence of gut symptoms
• Patients with coeliac disease should have
screening bone density especially at menopause.
• Patients with coeliac disease may not tolerate
oral medications, particularly calcium
supplements and oral bisphosphonates.
Keogh Institute for
Medical Research