We get many questions about the management of osteoporosis, especially whether patients should be placed on agents that act on the bones as anti-resorption agents such as Fosamax. We have advocated that patients with reduced bone density, and celiac disease, be treated by the use of calcium supplements and a gluten-free diet. Only if the bone density does not improve, and calcium absorption normalizes, would we advocate use of these drugs. Bone density usually improves on this regime.

A patient sent us information that they received from the manufacturer of Fosamax, Merck & Co. We also checked with Merck. We received information concerning Fosamax (alendronate sodium) tablets and oral solution. Their information states that Fosamax is not indicated for the treatment of osteoporosis secondary to Chron's disease, inflammatory bowel disease, celiac disease or malabsorption syndromes.

Here is what we advise. Serum calcium (the calcium in the blood) is maintained carefully for heart and muscle function by absorption from the gut, and from resorption from the bones. In the setting of active celiac disease and poor absorption of calcium, due to malabsorption, the bones are providing the main source of the serum calcium. The addition of a medication blocking bone resorption can result in a fall in serum calcium. Therefore, we advise that osteoporosis, in patients with celiac disease, be initially treated with a gluten-free diet and adequate oral calcium. This should be for at least a year. Then a repeat of the bone mineral density can be performed. If necessary, Fosamax can be added if there is adequate calcium absorption. Calcium absorption is usually assessed by a 24 hour urinary calcium test.

We have seen many patients with both celiac disease and osteoporosis that are doing well on drugs that include Fosamax and similar drugs. However, caution should be used if they are administered early in the course of celiac disease.

This information should not replace information provided from your physician who has detailed knowledge of individual patient’s care.

From the Celiac Disease Center at Columbia University.