Timing the Scan: Optimizing Screening for Osteoporosis and Risk of Fracture in Celiac Disease

Patients with celiac disease (CeD) have an increased risk of osteoporosis and fractures, but the ideal timing for bone mineral density (BMD) assessment remains unclear due to conflicting recommendations. This study evaluated the optimal timing for dual-energy x-ray absorptiometry (DXA) screening considering different clinical targets: early detection of BMD alterations, osteoporosis diagnosis, or fracture risk stratification.

Observational study prospectively enrolling 627 patients with CeD (>25 years) who underwent DXA scans of the lumbar spine and hip as part of standard care. Data on clinical presentation, serology, histology, and fracture risk were analyzed. Logistic regression identified risk factors of low BMD and osteoporosis. The reliability of the National Osteoporosis Guidelines Group (NOGG) guidelines for avoiding unnecessary DXAs was assessed.

Low BMD for age was present in 17.2% of patients, with significant prevalence in the 25-34 years age group (13.4%), further increasing in the 45-54 years age group. Osteoporosis was detected in 17.9% of patients, with prevalence increasing significantly in patients aged older than 45 years. Risk factors included weight loss, underweight status, and iron-deficiency anemia. Using the NOGG criteria, 67% of patients could have avoided DXA, with a 0.5% risk of missing clinically significant findings requiring treatment (but also losing 15.7% patients with low BMD for age).

The ideal timing for DXA screening in patients with CeD depends on the clinical objective. DXA at diagnosis maximizes the early detection of low bone mass, whereas the NOGG criteria effectively identified patients at high risk of fractures, reducing unnecessary scans. However, their use should be weighed against an underdetection of clinically relevant BMD alterations. Tailoring DXA timing to healthcare resources and patient demographics may optimize outcomes and resource allocation.