What is the management plan for celiac disease?

Management of Celiac Disease

The primary and only effective treatment for celiac disease is strict lifelong adherence to a gluten-free diet (GFD) with an intake of less than 10 mg of gluten per day. 1

Initial Management Steps

Dietary Management

• Strict gluten-free diet for life:
  • Complete elimination of wheat, barley, and rye proteins 1
  • Pure oats may be introduced slowly with careful monitoring for adverse reactions 1
  • Target less than 10 mg gluten intake per day 1

Nutritional Assessment and Support

• Immediate referral to a dietitian with expertise in celiac disease for 1:

  • Comprehensive nutritional assessment
  • Education about the gluten-free diet
  • Meal planning assistance
  • Support for adaptation to the gluten-free lifestyle

• Testing for micronutrient deficiencies at diagnosis 1:

  • Iron
  • Folic acid
  • Vitamin D
  • Vitamin B12
  • Other nutrients as clinically indicated

Monitoring Protocol

Regular Follow-up

• Monitor patients regularly for 1, 2:
  • New or residual symptoms
  • Adherence to the diet
  • Assessment for complications
  • Special attention to growth and development in children

Adherence Assessment

• Use a combination of 1:
  • Patient history
  • Serological testing (tTG-IgA, EMA-IgA)
  • Verification that clinical abnormalities have normalized

Follow-up Testing

• Serological testing at 6 and 12 months after diagnosis, then yearly 2
• Consider follow-up intestinal biopsy after 1-2 years to confirm mucosal healing 2

Management of Non-Responsive Celiac Disease (NRCD)

If symptoms persist despite apparent adherence to a GFD (affects 4-30% of patients) 1:

1. Confirm the original diagnosis 1, 2:

   • Review biopsy results
   • Review serology and HLA status

2. Assess dietary adherence with an expert dietitian 1

3. If adherence is confirmed but symptoms persist, investigate for:

   • Microscopic colitis 1
   • Small intestinal bacterial overgrowth (SIBO) 1
   • Exocrine pancreatic insufficiency 1
   • Thyroid dysfunction 1
   • Lactose intolerance 1, 2
   • Fructose intolerance 1
   • FODMAPs sensitivity 1, 2

4. If symptoms relapse or no clinical response:

   • Perform upper endoscopy with bowel biopsies 1

Management of Refractory Celiac Disease (RCD)

If symptoms and villous atrophy persist despite confirmed strict GFD adherence for at least 12 months 2:

1. Perform advanced testing:

   • Flow cytometry
   • Immunohistochemistry
   • T-cell receptor rearrangement studies

2. Distinguish between RCD types:

   • Type 1 (RCDI)
   • Type 2 (RCDII) - characterized by monoclonal population of T cells or aberrant T cells

Special Considerations

Nutritional Balance

• The GFD must be not only free of gluten but also nutritionally balanced 3, 4
• Include alternative gluten-free grains such as buckwheat, amaranth, quinoa, millet, and sorghum 2
• Monitor for and address common deficiencies in B vitamins, iron, calcium, vitamin D, zinc, magnesium, and fiber 2, 4

Quality of Life Considerations

• Recognize that the GFD poses difficulties in family, social, and working contexts 3
• Provide resources for managing these challenges
• Consider referrals to celiac support groups 5

Future Treatments

While pharmacologic therapies are in development, they are intended to complement rather than replace the gluten-free diet 6. Currently, a strict GFD remains the only proven treatment for celiac disease.