What is the treatment for coeliac disease?

Treatment of Coeliac Disease

The only effective treatment for coeliac disease is strict, lifelong elimination of all wheat, rye, and barley proteins from the diet, with daily gluten intake limited to less than 10 mg. 1, 2

Core Treatment: The Gluten-Free Diet

• Complete gluten elimination is mandatory for life, as this is the only accepted medical nutrition therapy for coeliac disease 1, 2
• Patients must avoid all products containing wheat, rye, and barley proteins 2, 3
• The safe threshold for daily gluten intake is less than 10 mg per day, though some guidelines suggest up to 50 mg may be tolerated without causing mucosal damage 1, 4
• Gluten-free products should contain less than 20 parts per million of gluten to be considered safe 4

Oats Consideration

• Pure, uncontaminated oats may be introduced at diagnosis and are generally safe for most patients with coeliac disease 1, 3
• However, oats should be introduced slowly with careful monitoring for adverse reactions, as contamination of commercial oats remains a concern 1, 3

Essential Multidisciplinary Management

Immediate Dietitian Referral

• Referral to an experienced dietitian specializing in coeliac disease is essential at the time of diagnosis 2, 3, 5
• The dietitian should provide nutritional assessment, education on gluten-free diet implementation, meal planning, and assistance with lifestyle adaptation 2, 5
• This referral must be immediate, not delayed, as proper dietary education is critical for treatment success 2, 3

Nutritional Assessment and Supplementation

Test for micronutrient deficiencies at diagnosis, including: 2, 3

• Iron
• Folate
• Vitamin D
• Vitamin B12
• Vitamin B6
• Zinc
• Magnesium

Address nutritional gaps proactively, as gluten-free products are typically low in B vitamins, calcium, vitamin D, iron, zinc, magnesium, and fiber, with few products being fortified or enriched 1, 2, 6

Monitoring and Follow-Up Protocol

Regular Assessment Schedule

• Schedule follow-up visits every 6-12 months to monitor dietary adherence and nutritional adequacy 2, 3
• Use a combination of clinical history, serology (anti-tissue transglutaminase antibodies), and dietitian assessment to monitor gluten-free diet adherence 2, 3
• Verify that initial laboratory abnormalities have normalized 2
• Monitor growth parameters closely in children, as poor growth indicates ongoing disease activity or nutritional deficiencies 3

Weight Monitoring

• Monitor for both underweight and overweight/obesity, as there is an increased incidence of obesity in patients following a gluten-free diet 1, 7, 6
• A strict gluten-free diet may help patients reach ideal body weight, whether underweight or obese at diagnosis 1

Management of Non-Responsive Coeliac Disease

When symptoms persist despite apparent dietary adherence (affecting 4-30% of patients): 1

1. Confirm the original diagnosis by reviewing initial biopsy, serology, and HLA status 1, 2
2. Thoroughly review the diet for hidden gluten sources with an experienced dietitian, as inadvertent or deliberate gluten exposure is the most frequent cause of non-responsive disease 1, 2, 3
3. Perform follow-up biopsy to assess for ongoing enteropathy 1
4. Exclude other conditions including Giardia, microscopic colitis, exocrine pancreatic insufficiency, small intestine bacterial overgrowth, lactose intolerance, and hyperthyroidism 1
5. Consider small bowel imaging if abdominal pain, fever, obstruction, anemia, gastrointestinal bleeding, or unexplained weight loss is present 1

Critical Pitfalls to Avoid

• Never initiate a gluten-free diet before completing diagnostic testing (serology and biopsy), as this leads to false-negative results and makes diagnosis impossible 2
• Failure to address nutritional deficiencies can delay or prevent symptom resolution, particularly neuropsychiatric symptoms 2
• Do not assume patients understand "gluten-free" without proper dietitian education, as gluten exists as both an ingredient and hidden component, with risk of cross-contamination 7
• Avoid focusing solely on gluten elimination without ensuring the diet is nutritionally balanced and healthy 7, 6

Quality of Life Considerations

• Patients commonly experience limitations in social life due to difficulty accessing safe gluten-free meals when eating out 1
• The cost of gluten-free food is substantially higher than equivalent wheat-based foods 1
• Education about gluten-free diet needs to be directed to catering personnel, as chefs' knowledge about coeliac disease is often lower than that of the general public 1
• Adherence to the gluten-free diet is better achieved when patients are well educated and supported by carers and families 1