FOCUS ON MALE OSTEOPOROSIS

Addendum: A related article appeared on Science Daily (July 25, 2008) soon after most of the following was originally posted. Note, however, that the claim that "It is widely known that among adults [with celiac disease] gluten-free diet alone is not sufficient make the bone damage regress" is something of an overstatement, as a calcium rich gluten-free diet can result in at least some improvement.

Celiac disease is a risk factor for osteoporosis, including male osteoporosis, as noted in Dawn Klingensmith's Philadelphia Inquirer article "Tough Men, Brittle Bones" (July 28, 2008).

As described in Celiac Disease: A Hidden Epidemic, osteoporosis or some other form of bone disease is actually common among people with undiagnosed celiac disease, with the men tending to have the lower bone density.

Approximately 75 percent of newly diagnosed patients with celiac disease have some degree of bone loss. Recent studies show that up to 35 percent of adults who are newly diagnosed with celiac disease have established osteoporosis. While both osteoporosis and celiac disease are more common in women, low bone density is an equal-opportunity complication in the celiac community. And men with celiac disease tend to have more severe osteoporosis.

So doctors and patients should be alert to the possibility that men can have osteoporosis, and that celiac disease is a risk factor. A man (or woman) who tests positive for celiac disease should be considered as also being at risk for osteoporosis—even when a CBC doesn't send up any red flags, the celiac diagnosis is in itself a red flag. Likewise a patient who tests positive for osteoporosis or osteopenia should be considered as possibly having untreated celiac disease—especially if a cause of the condition seems hard to determine. [See related article.]

Many medical professionals may recommend testing for osteoporosis for patients at an advanced or after a fracture. However, in this layperson's opinion, an early baseline test is worth serious consideration.

As noted elsewhere in this blog, current drug therapies for osteoporosis seem to yield encouraging results, but there may be significant negative side effects from, say, taking oral bisphosphonates for more than five consecutive years, or from taking intravenous treatment if a patient is not properly vetted for dental and other issues.

If early testing (say, between 20 and 40) reveals a bone density problem, the condition may be largely or entirely treatable with diet and exercise, even if the patient has just started a gluten-free diet after being newly diagnosed with celiac disease. Celiac Disease: A Hidden Epidemic puts it this way: "The overwhelming evidence and statistics that connect celiac disease to osteopenia and osteoporosis make a compelling case for prevention as well as early screening for the conditions. Early diagnosis and therapy are critical to permit patients with celiac disease to achieve normal peak bone mass and then maintain it."

STUDY: FOSAMAX INCREASES RISK OF ATRIAL FIBRILLATION

People who have lived with untreated celiac disease are at an above-average risk for osteoporosis. So it is a good idea to have one's bone density tested subsequent to a positive diagnosis for celiac disease.

If the patient turns out to have osteoporosis, it is likely that therapies will be considered. The very good news is that patients seem to have a very good track record rebuilding at least some bone density through a well-rounded gluten-free diet, supplementation, and exercise. However, physicians may also suggest medicinal therapy involving bisphosphonates such as Fosamax and Reclast.

Before beginning a regimen of such drugs, it is a good idea to thoroughly discuss the risks and benefits with an informed specialist. With Fosamax, there has been some concern over stress fractures and slow healing after continuing use of the drug for more than five years; with a drug such as Reclast, it seems that patients should be vetted for possible osteonecrosis of the jaw. And just this January, the FDA issued a warning about severe bone, joint, and/or muscle pain due to such bisphosphonates.

Furthermore, recent studies now suggest that women on Fosamax and Reclast may also risk atrial fibrillation.

There still may be good rationales for treating osteoporosis with these medications; it just seems to be a good idea to weigh the pluses and minuses while keeping in mind that, for people newly diagnosed with celiac disease as well as osteoporosis, simply adopting a gluten-free diet and getting appropriate nutrition can yield very good results.

As a layperson, I also find that general screening for osteoporosis looks better and better to me. In many cases, the condition seems to be more improvable the sooner it is detected, so I don't see the harm in getting baseline diagnoses early (even in one's twenties) and perhaps every ten years after that to heighten the chance of nipping the condition in the bud and perhaps reversing it before it becomes more serious. The same goes for celiac disease, especially among people who display risk factors such as chronic fatigue, gastrointestinal problems, and/or having a first or second degree relative who has been conventionally diagnosed. In both cases, early detection can lead to early, relatively simple treatment that leads to greater success with fewer medications.

OSTEOPOROSIS DRUG ALERT

Adults diagnosed with untreated celiac disease should have their bone density checked because many—men included—have low bone density. After adopting a gluten-free diet, such people often show dramatic improvement without taking osteoporosis medication such as bisphosphonates. However, physicians may still consider prescribing bisphosphonates to improve bone density.

Although many people appear to use bisphosphonates safely, concerns about the medication have come up periodically. Necrosis has received some attention, though I have been told that it is very rare. Jane Brody at The New York Times (July 5, 2005) reported on a possibile association of slow-healing non-traumatic stress fractures with the use of bisphosphonates for more than five years.

And now the FDA has issued an alert about severe bone, joint, and/or muscle pain while taking a bisphophonate:

FDA is highlighting the possibility of severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain in patients taking bisphosphonates. Although severe musculoskeletal pain is included in the prescribing information for all bisphosphonates, the association between bisphosphonates and severe musculoskeletal pain may be overlooked by healthcare professionals, delaying diagnosis, prolonging pain and/or impairment, and necessitating the use of analgesics.

The severe musculoskeletal pain may occur within days, months, or years after starting a bisphosphonate. Some patients have reported complete relief of symptoms after discontinuing the bisphosphonate, whereas others have reported slow or incomplete resolution. The risk factors for and incidence of severe musculoskeletal pain associated with bisphosphonates are unknown.

This severe musculoskeletal pain is in contrast to the acute phase response characterized by fever, chills, bone pain, myalgias, and arthralgias that sometimes accompanies initial administration of intravenous bisphosphonates and may occur with initial exposure to once-weekly or once-monthly doses of oral bisphosphonates. The symptoms related to the acute phase response tend to resolve within several days with continued drug use.

Healthcare professionals should consider whether bisphosphonate use might be responsible for severe musculoskeletal pain in patients who present with these symptoms and consider temporary or permanent discontinuation of the drug.

Bisphosphonates are marketed as Actonel, Actonel+Ca, Aredia, Boniva, Didronel, Fosamax, Fosamax+D, Reclast, Skelid, and Zometa.