What is the treatment for celiac disease?

Treatment of Celiac Disease

The only effective treatment for celiac disease is strict lifelong adherence to a gluten-free diet (GFD), which requires complete elimination of wheat, rye, and barley proteins. 1, 2

Gluten-Free Diet Implementation

• A strict GFD must eliminate all sources of gluten, including hidden sources and cross-contamination, to achieve less than 10 mg gluten intake per day 1
• Consultation with a registered dietitian with expertise in celiac disease is essential for proper nutritional assessment, education, and meal planning 1, 2
• The diet should focus on naturally gluten-free foods including:
  • Rice, corn, potatoes, buckwheat, amaranth, quinoa, millet, and sorghum 1, 2
  • Fresh fruits, vegetables, meats, fish, dairy, and legumes 2
• Pure oats may be introduced gradually into the diet with careful monitoring for adverse reactions 1, 2
• Patients must learn to read food labels carefully and understand potential sources of cross-contamination 3

Nutritional Considerations

• The GFD must be nutritionally balanced as many gluten-free products are low in:
  • B vitamins, calcium, vitamin D, iron, zinc, magnesium, and fiber 1, 4
• Testing for micronutrient deficiencies (iron, folate, vitamin D, vitamin B12) is recommended at diagnosis 2
• Bone mineral density assessment should be performed to evaluate for osteoporosis 2
• Treatment of identified nutritional deficiencies is essential 2
• Weight monitoring is important as both malnutrition and obesity can occur in patients following a GFD 1, 4

Monitoring and Follow-up

• Regular follow-up with a healthcare team including physician and dietitian is necessary 2
• Monitoring should include:
  • Assessment of symptoms and dietary adherence through structured dietary interviews 1
  • Serological testing (anti-TG2 or EMA/DGP antibodies) to assess adherence 1
  • Laboratory tests to monitor nutritional status and associated conditions 1
• Annual follow-ups are recommended once the disease is stable 1, 5
• Follow-up biopsies may be considered but are not mandatory if the patient is asymptomatic on a GFD 1
• Follow-up biopsies should be performed in patients who do not respond to a GFD 1

Management of Non-responsive Celiac Disease

• For patients with persistent or recurrent symptoms despite a GFD (non-responsive celiac disease):
  • Review dietary adherence with an expert dietitian as inadvertent gluten exposure is the most frequent cause 1
  • Perform serologic testing to assess ongoing gluten exposure 1
  • Consider follow-up biopsy to evaluate for persistent enteropathy 1
  • Evaluate for other conditions such as microscopic colitis, pancreatic exocrine insufficiency, bacterial overgrowth, and disaccharidase deficiency 1

Special Considerations: Dermatitis Herpetiformis

• Dermatitis herpetiformis (DH) is the cutaneous manifestation of celiac disease 5
• Treatment includes:
  • Strict GFD as the cornerstone therapy 5
  • Dapsone as initial adjunctive therapy to rapidly control skin symptoms 5
  • More than 70% of patients can discontinue dapsone within 24 months of strict GFD adherence 5, 1

Benefits of Treatment

• Adherence to a GFD results in:
  • Resolution of symptoms and intestinal inflammation 1, 2
  • Improvement in nutritional deficiencies 2
  • Increased bone mineral density 2
  • Decreased risk of non-Hodgkin's lymphoma and other complications 1, 2, 5
  • Improved quality of life when properly implemented 6

Common Challenges

• Social limitations due to difficulty accessing gluten-free meals 1
• Higher cost of gluten-free products compared to wheat-based foods 1
• Risk of nutritional inadequacies if diet is not properly balanced 1, 4
• Potential for inadvertent gluten exposure through cross-contamination 3
• Negative serological tests do not necessarily indicate complete mucosal healing 5