MON-794 Bones and Groans: Managing Osteoporosis in Celiac Disease

Abstract Disclosure: S. Silva-Echeandia: None. J. Fathelbab: None. A. Raj: None. K. Jong: None. Celiac disease (CD) is an emerging global issue, affecting about 1% of the population worldwide. While known to cause abdominal pain, bloating, and diarrhea, its extra-intestinal manifestations of low bone mineral density (BMD) and osteoporosis (OP) are often overlooked. We present a case of CD diagnosed due to elevated parathyroid hormone (PTH) level and OP-range BMD in order to discuss treatment considerations in this population. A 73-year-old man with rheumatoid arthritis is referred for elevated PTH level. He has no history of fractures or kidney stones. He weighs 72kg with a BMI of 21.60 kg/m2. He takes vitamin D and magnesium. Prior calcium levels were low-normal (8.0-8.7 mg/dL) and he reports very little dietary calcium intake. Labs show PTH 210.9 pg/mL, vitamin D 29.6ng/mL, calcium 9.0, albumin 4.3, creatinine 0.96, eGFR 83, phosphorus 4.0, magnesium 2.1. After 2 weeks of calcium carbonate supplementation, his 24-hour urine calcium is undetectable. DXA shows osteoporosis with T-score -2.8 at left femoral neck. On further questioning, patient does report frequent loose stools for several years, but has no abdominal pain. Despite switching to calcium citrate supplementation, 24-hour urine calcium remains undetectable. Celiac panel is positive, and he has other vitamin and mineral deficiencies consistent with malabsorption. He is referred to GI and subsequent small bowel biopsy shows celiac disease. He is started on a gluten-free diet with calcium citrate, cholecalciferol, magnesium, zinc, iron, and B12 supplementation with plans to repeat DXA scan in 1 year prior to starting any targeted osteoporosis treatment. The etiology of low BMD in CD is well-known, including both malabsorption of calcium and vitamin D from gluten-induced villous atrophy and increased osteoclast activity from pro-inflammatory cytokines. OP-range BMD is present at the time of CD diagnosis in about 18-35% of patients; however, there is little guidance on screening or management of OP in these patients. While some groups recommend bisphosphonates according to general OP guidelines for post-menopausal women, this approach may not benefit CD patients as it fails to account for impact of osteomalacia and secondary hyperparathyroidism affecting BMD. Indeed, premature treatment with bisphosphonates may actually hinder BMD recovery by reducing bone turnover. We chose to treat first with gluten-free diet and vitamin/mineral supplementation and anticipate that he will have significant improvement in BMD with these modifications alone, potentially obviating a need for targeted OP therapy. Presentation: Monday, July 14, 2025