Treat
Coeliac
Left untreated, coeliac disease may result in serious long-term health complications. The only effective treatment for coeliac disease is life-long adherence to a gluten-free diet,1 which can reverse villous atrophy and reduce associated morbidities.2
However, a gluten-free diet should only be initiated once all necessary serologic tests for coeliac disease have been finished.3
My patient has coeliac disease, confirmed by a gastroenterologist. What’s next?
There are several ways in which you can manage and support your patient at the time of their diagnosis:3,4
Physical examination
Look for any comorbidities or signs of nutrient deficiencies and calculate your patient’s BMI.
Routine blood tests
These should include complete tTG IgA test, blood count, iron, folate, vitamin B12, thyroid function, liver enzymes, calcium, phosphate, alkaline phosphatase, and vitamin D. Any nutrient deficiencies should be rectified as necessary.
Bone densitometry
A baseline bone density measurement is needed in adults, especially in those with risk-factors for low bone mineral density (BMD), such as:
- Malabsorption
- Clinical presentation suggestive of bone disease
- A long delay in diagnosis of coeliac disease
- Perimenopausal or menopausal women
- Men aged >50 years
- History of fragility fracture
Adults with no obvious risk-factors for low BMD should have a bone density scan at no later than 35 years of age.
Dietary advice
Advise your patient that to manage their condition, they should adhere to a gluten-free diet for life. In order to help your patient do this, referral to a dietitian is required.
Coeliac societies and support groups
Patients should be encouraged to join national coeliac societies or other relevant patient support groups, such as Coeliac UK.
Family screening
Susceptibility to coeliac disease is hereditary; first-degree family members of affected patients should be screened for the condition.
How should coeliac disease be monitored?
Patients are more likely to adhere to a gluten-free diet if they are regularly followed up in a specialist coeliac clinic, with input from a dietitian and a gastroenterologist.3
In the first year following a diagnosis follow-up should be frequent to increase the likelihood of dietary adherence, provide psychological support, and help the patient adapt to living with coeliac disease. Once the disease is stable, annual follow-up may be initiated.3
At each appointment, it’s recommended to check serum tissue transglutaminase (tTG) IgA levels.3
- It’s common practice for tTG IgA to be tested 2-3 times per year until levels normalise, then once a year to monitor disease activity.5
- A decline in tTG IgA titers is an indication of good dietary adherence.3
It’s also important to monitor:3
- Symptoms and coping skills
- The gluten-free diet plan
- Nutritional status, height, and weight
- Blood markers, as clinically indicated (e.g., to look for associated autoimmune conditions)
IgA: immunoglobulin A
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1. Gujral N, Freeman H J, Thomson A B. Celiac disease: prevalence, diagnosis, pathogenesis and treatment. World J Gastroenterol 2012;18(42):6036-6059
2. Ciacci C, Ciclitira P et al. The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis. United European Gastroenterol J 2015;3(2):121-135
3. Al-Toma A, Volta U et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J 2019;7(5):583-613
4. Rubio-Tapia A, Hill I D et al. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 2013;108(5):656-676;quiz 677
5. Pinto-Sanchez M I, Bai J C. Toward new paradigms in the follow up of adult patients with celiac disease on a gluten-free diet. Front Nutr 2019;6:153