Bone protection in coeliac disease

The role of FRAX and NOGG

The National Osteoporosis Guideline Group (NOGG) recommends that fracture risk should initially be assessed using FRAX (or QFracture) in postmenopausal women and men aged over 50 years with clinical risk factors for osteoporosis. In younger adults, osteoporosis assessment is less protocol-driven and instead relies on individual clinical judgement, evaluation of secondary causes, fracture history and specialist assessment where indicated (National Osteoporosis Guideline Group [NOGG], 2024). FRAX estimates an individual’s 10-year probability of major osteoporotic and hip fracture.

Hip fracture patients are then stratified into:

Case scenario

A 52-year-old woman attends following diagnosis of CD after investigation for iron deficiency anaemia. She has a BMI of 18.5 and entered menopause at age 47. She is a non-smoker with no history of fractures.

Her GP calculates her FRAX score (www.fraxplus.org/calculation-tool), which places her in the intermediate-risk category.

According to NOGG (2024), an intermediate FRAX result should prompt DEXA scanning to refine fracture risk assessment.

Dilemma of the intermediate FRAX and DEXA

Dual-energy X-ray absorptiometry (DEXA) is the gold-standard investigation for assessing bone mineral density (BMD) and plays a central role in the diagnosis of osteoporosis. DEXA results are reported as a T-score, which compares an individual’s bone density with that of a healthy young adult reference population. A T-score above −1 is considered normal, values between −1 and −2.5 indicate osteopenia and a T-score of −2.5 or below is diagnostic of osteoporosis.

A common clinical challenge in osteoporosis management arises when interpreting DEXA findings in patients initially categorised as having an intermediate fracture risk based on FRAX assessment. Clinicians may incorrectly assume that the presence of osteopenia or osteoporosis on DEXA alone mandates immediate treatment.

However, DEXA is not intended to function as an isolated diagnostic tool in this context. Rather, its purpose is to refine fracture risk estimation in patients whose baseline FRAX score does not clearly indicate either reassurance or treatment. In such cases, the appropriate next step is to recalculate the FRAX score with the measured BMD incorporated into the algorithm.

This updated calculation provides a more accurate estimate of the patient’s 10-year fracture probability and may reclassify the individual into a low, high or very high risk category, thereby guiding subsequent management decisions. This stepwise approach ensures that treatment decisions are based on overall fracture risk rather than bone density alone, helping to avoid both overtreatment and undertreatment.

Management

NOGG recommends initiation of pharmacological treatment in individuals whose fracture risk, as determined by FRAX with or without bone mineral density input, exceeds the established intervention threshold. Treatment is also indicated in the presence of a fragility fracture, radiologically confirmed vertebral fracture or when clinical judgement suggests that calculated fracture risk may substantially underestimate the patient’s true risk.

In most cases, first-line pharmacological management consists of weekly oral bisphosphonate therapy, typically alendronic acid, owing to its established efficacy, safety profile and cost-effectiveness in reducing fracture risk. If alendronic acid is contraindicated, not tolerated or unsuitable, NICE and NOGG recommend risedronate as an alternative oral bisphosphonate. Where oral treatment is unsuitable, such as in oesophageal disease, poor adherence or malabsorption, intravenous zoledronic acid is an effective alternative. Other options include ibandronate, particularly for vertebral fracture prevention, and denosumab, a 6-monthly injectable option requiring careful long-term planning owing to rebound fracture risk if stopped abruptly. In selected cases, raloxifene, hormone replacement therapy, or anabolic therapies such as teriparatide and romosozumab, may also be considered (NOGG, 2024).

However, optimal osteoporosis management extends beyond pharmacotherapy alone and should adopt a holistic approach to bone health preservation. In patients with coeliac disease, strict adherence to a gluten-free diet is essential, as ongoing gluten exposure may perpetuate malabsorption and contribute to continued bone loss. Correction of calcium and vitamin D deficiency is equally important to support bone mineralisation and maximise treatment efficacy.

Lifestyle modification should also be encouraged, including regular weight-bearing and resistance exercise to promote skeletal strength, smoking cessation to reduce modifiable fracture risk and comprehensive falls risk assessment with implementation of preventative strategies where appropriate. Together, these measures form an integrated management strategy aimed at reducing fracture risk and optimising long-term skeletal health.