Metabolic Bone Disease in Coeliac Disease: Protecting Bone, Resources, or Both?

We read with great interest the updated European Society for the Study of Coeliac Disease (ESsCD) guidelines on the management and follow-up of coeliac disease (CD) in adults, which provide a timely, evidence-based update on several aspects of patient care 1. Regarding the management of metabolic bone disease, we appreciate that the guidelines clearly introduce, for the first time, the concept of a personalized approach. Avoiding unnecessary dual-energy x-ray absorptiometry (DXA) examinations not only represents a rational use of healthcare resources but also reduces patient burden in terms of time, costs, and anxiety. In this context, the authors suggest performing DXA in patients aged > 35 years or with additional risk factors. While this threshold likely reflects a pragmatic compromise, there is limited evidence supporting this age cut-off or the proposed use of FRAX in this age group 2. Also, metabolic bone disease in CD represents a form of secondary osteoporosis, in which risk may not fully reflect the classical determinants identified in postmenopausal osteoporosis, potentially leading to under-recognition of early bone impairment. Indeed, in a recent study from our group, low bone mineral density (BMD) was frequently detected, even in patients younger than 35 years (13.4%), and in the absence of overt risk factors 3. This non-negligible proportion is particularly relevant, as younger individuals may represent the subgroup most likely to benefit from early identification and timely correction of modifiable factors, with potential long-term effects on bone health and fracture prevention. We acknowledge that a universal DXA strategy may increase initial costs. However, this approach could be balanced by a parsimonious follow-up strategy. In a cohort of patients followed for 10 years, individuals without osteoporosis or additional risk factors showed minimal variation in BMD parameters and FRAX score over time, suggesting that repeated DXA examinations in this subgroup may yield limited additional clinical information 4. We therefore consider the updated recommendations on follow-up to represent a meaningful improvement compared with previous ESsCD guidance, which suggested fixed-interval reassessment in patients with any degree of BMD reduction at baseline DXA 5. In conclusion, while we support a personalized framework for bone health management in CD, caution may be warranted in relying exclusively on traditional risk factors or in considering DXA as non-mandatory at diagnosis, as this may result in missed opportunities for early intervention. A strategy based on early baseline assessment followed by risk-stratified follow-up may help optimize both clinical outcomes and resource utilization. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.