What is the management of coeliac disease?

Management of Coeliac Disease

The only effective treatment for coeliac disease is a strict, lifelong gluten-free diet (GFD) that completely avoids all products containing wheat, barley, and rye proteins. 1, 2

Initial Management After Diagnosis

Dietary Management

• Refer all newly diagnosed patients to a dietitian for nutritional assessment and counseling about implementing a gluten-free diet 1
• Educate patients on complete avoidance of:
  • Wheat, barley, and rye proteins
  • Hybrids of these grains (kamut, triticale)
  • Foods with potential cross-contamination 2
• Safe alternatives include:
  • Rice, corn, and potatoes as traditional substitutes
  • Certified gluten-free oats (introduce slowly and monitor for reactions)
  • Alternative grains: buckwheat, amaranth, quinoa, millet, and sorghum 2

Initial Testing

• Test for micronutrient deficiencies at diagnosis:
  • Iron
  • Folic acid
  • Vitamin D
  • Vitamin B12 1, 2
• Screen for associated conditions:
  • Thyroid function tests
  • Liver function tests
  • Blood glucose (for diabetes) 1

Monitoring and Follow-up

Regular Follow-up Schedule

• Follow-up at 6 and 12 months after diagnosis, then annually 2
• Each follow-up should include:
  • Assessment of symptoms
  • Dietary adherence review
  • Serological testing (anti-TG2 or EMA/DGP antibodies)
  • Verification that initial laboratory abnormalities have normalized 1

Monitoring Adherence

• Use a combination of:
  • Detailed dietary history
  • Serological testing (though not 100% sensitive for detecting non-adherence)
  • Consider testing for gluten immunogenic peptides in stool or urine 2

Assessing Response

• If symptoms persist or relapse despite reported adherence:
  • Consider upper endoscopy with bowel biopsies 1
  • Investigate for Non-Responsive Coeliac Disease (NRCD) causes:
    • Microscopic colitis
    • Small intestinal bacterial overgrowth
    • Exocrine pancreatic insufficiency
    • Lactose or fructose intolerance
    • Thyroid dysfunction
    • FODMAPs sensitivity 2

Special Considerations

Dermatitis Herpetiformis

• Patients with dermatitis herpetiformis (skin manifestation of coeliac disease) often require:
  • Strict GFD
  • Initial dapsone treatment for rash control

  • 70% of patients can wean off dapsone over 24 months with strict GFD adherence 1

Children with Coeliac Disease

• Special attention to ensure normal growth and development
• Monitor for dental manifestations (enamel defects, delayed eruption, recurrent aphthous ulcers) 3
• Regular assessment of nutritional status and growth parameters

Challenges and Pitfalls

Adherence Challenges

• Adherence rates vary between 45-90% 4
• Factors affecting adherence:
  • Age at diagnosis
  • Coexisting depression
  • Symptom severity with gluten ingestion
  • Knowledge of GF foods and food labels
  • Cost and availability of GF foods
  • Membership in coeliac support groups 4

Common Pitfalls

• Relying solely on symptom resolution to assess adherence (inadequate)
• Assuming normal serological markers indicate complete mucosal healing
• Overlooking hidden sources of gluten contamination
• Inadequate nutritional content of GFD (many GF products are low in essential nutrients) 2

Safe Gluten Limits

• Daily gluten intake should be <10 mg to avoid histological abnormalities
• Contamination between 10-100 mg may cause damage in sensitive individuals 1

Future Directions

While not yet approved, research is ongoing into alternative treatments targeting various mechanisms:

• Gluten-degrading enzymes
• Tight junction modulators
• Immune-targeted therapies 5, 6

However, these remain investigational, and a strict GFD remains the only proven effective treatment for coeliac disease.