What is the primary management strategy for celiac disease?

Management of Celiac Disease

The primary management strategy for celiac disease is strict adherence to a lifelong gluten-free diet (GFD), which requires complete avoidance of all products containing wheat, barley, and rye proteins. 1, 2

Implementing the Gluten-Free Diet

• Patients should adhere to a GFD with an intake of less than 10 mg of gluten per day 1
• Newly diagnosed patients should be referred to a dietitian for nutritional assessment and counseling about implementing a GFD 2
• Pure oats may be introduced slowly into the diet with monitoring for adverse reactions, as they are safe for most patients with celiac disease 1
• Alternative gluten-free grains such as buckwheat, amaranth, quinoa, millet, and sorghum should be incorporated to improve the nutritional profile of the diet 2
• Focus should be placed on natural gluten-free foods including extra-virgin olive oil, milk, yogurt, plant foods, and fish rich in omega-3 fatty acids 2

Initial Assessment and Monitoring

• Testing for micronutrient deficiencies (iron, folate, vitamin D, vitamin B12) should be performed at diagnosis 1, 2
• Bone mineral density should be assessed to evaluate for osteoporosis 2
• Any identified nutritional deficiencies should be treated appropriately 2
• Regular follow-up with both physician and dietitian is essential for optimal management 2

Follow-up and Monitoring

• Annual follow-ups should be initiated once the disease is stable and patients manage their diet without problems 1
• Follow-up should include:
  • Assessment of small intestinal absorption (full blood count, ferritin, serum folate, vitamin B12, calcium, alkaline phosphatase) 1
  • Screening for associated autoimmune conditions (thyroid function tests, serum glucose) 1
  • Liver function tests (AST/ALT) 1
  • Dietary adherence assessment (anti-TG2 or EMA/DGP antibodies, plus structured dietary interview) 1
• A combination of history and serology should be used to monitor adherence to the GFD 1, 2
• Verification that clinical abnormalities detected on initial laboratory investigations have normalized 1, 2

Follow-up Biopsies

• Follow-up biopsies may be considered and are potentially helpful in identifying patients at increased risk of lymphoma 1
• Follow-up biopsies are not mandatory if the patient is asymptomatic on a GFD and has no other features suggesting increased risk of complications 1
• Follow-up biopsies should be undertaken in patients whose condition does not respond to a GFD 1

Management of Non-responsive Celiac Disease

• 4-30% of patients report persisting symptoms after adopting a GFD and are considered to have non-responsive celiac disease (NRCD) 1
• When symptoms persist or recur:
  • Confirm the initial diagnosis of celiac disease 1
  • Assess adherence to the GFD by an expert dietitian, as inadvertent or deliberate gluten exposure is the most frequent cause of NRCD 1
  • Consider follow-up biopsy to assess ongoing enteropathy 1
  • Consider other conditions such as microscopic colitis, pancreatic exocrine insufficiency, bacterial overgrowth, and disaccharidase deficiency 2

Benefits of Strict GFD Adherence

• Decreases excess risk of lymphoma 1, 2
• Improves nutritional parameters 2
• Increases bone mineral density, with greatest improvements in the first years of treatment 2
• In patients with dermatitis herpetiformis, more than 70% on a strict GFD are able to slowly wean off dapsone over a period of 24 months 1

Common Challenges and Pitfalls

• Availability of gluten-free food is limited in rural areas, and shopping for gluten-free food is time-consuming 1
• Gluten-free products are significantly more expensive than equivalent wheat-based foods 1
• Social limitations due to difficulty accessing gluten-free meals or concerns about food safety when eating out 1
• Chefs' knowledge about celiac disease is often lower than that of the general public, making dining out challenging 1
• Patients may develop overweight/obesity, so weight management deserves attention during follow-up 3
• A lack of symptoms or negative serological markers are not reliable indicators of mucosal response to diet 1

While pharmacologic therapies for celiac disease are being developed to address the limitations of dietary treatment 4, 5, they are still in clinical trials and not yet approved for use in practice 6, 7. The GFD remains the only proven effective and safe treatment for celiac disease.