Osteoporosis and coeliac disease
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7236.715 (Published 11 March 2000) Cite this as: BMJ 2000;320:715
Screening all patients with osteoporosis would be inappropriate
- W E Fickling, research registrar (Will.Fickling{at}btinternet.com),
- A K Bhalla, consultant rheumatologist
- Royal United Hospital, Bath BA1 3NG
- Royal National Hospital for Rheumatic Diseases, Bath BA1 1RL
- Department of Immunology, St James's Hospital and Trinity College Dublin, Dublin 8, Republic of Ireland
EDITOR—In his review of coeliac disease Feighery comments on the high incidence of osteoporosis in coeliac patients and says that this may be a presenting feature.1 He goes further to recommend, however, that all patients with osteoporosis should be screened for coeliac disease by measurement of endomysial antibodies.1 Most patients with osteoporosis do not have coeliac disease, and it is our experience that it is unusual for such patients to present without some other feature of coeliac disease. In their survey of 92 patients with osteoporosis Lindh et al comment that none of those patients found to have coeliac disease had intestinal symptoms, but no mention was made of anaemia.2 Such a proposal would have considerable implications for resources, both in the cost of the assays and in the substantial number of patients that would require referral to the gastroenterologists for intestinal biopsy. We suggest that screening for coeliac disease be reserved for when unexplained osteoporosis presents in association with anaemia or low serum concentrations of calcium in permanently tired premenopausal women and men aged 60 years who have a family history of coeliac disease or any gastrointestinal symptoms.
References
Author's reply
- Conleth Feighery, professor of immunology
- Royal United Hospital, Bath BA1 3NG
- Royal National Hospital for Rheumatic Diseases, Bath BA1 1RL
- Department of Immunology, St James's Hospital and Trinity College Dublin, Dublin 8, Republic of Ireland
EDITOR—I agree with Fickling and Bhalla that it would be inappropriate to screen all patients with osteoporosis for coeliac disease. The statement in the review that “all patients” should be screened is overenthusiastic and should be amended to read “all patients with unexplained osteoporosis.” Because of the high prevalence of coeliac disease, in particular clinically silent disease, I believe that patients with unexplained osteoporosis should be screened for coeliac disease even when there are no additional clinical clues pointing towards coeliac disease. We screened 371 female patients with suspected, but unexplained, osteoporosis and confirmed coeliac disease in five patients; two further patients were persistently positive for endomysial antibody but refused small intestinal biopsy. The findings have been submitted for publication.