What tests are recommended for routine Coeliac disease management?

Routine Blood Tests for Coeliac Disease Management

For routine six-month monitoring of established coeliac disease in an asymptomatic patient, you should order: anti-tissue transglutaminase IgA (anti-TG2), complete blood count, iron studies (ferritin), folate, vitamin B12, vitamin D, calcium, and liver enzymes. 1

Core Monitoring Panel

The 2024 Nature Reviews Gastroenterology & Hepatology guidelines provide the most current evidence-based recommendations for routine coeliac disease monitoring:

Essential Tests (Every 6-12 Months)

• Anti-TG2 IgA antibodies: Strongly recommended to monitor gluten-free diet adherence, though persistent elevation suggests gluten exposure while normalization does NOT reliably indicate mucosal healing 1

• Complete blood count: Essential for detecting anemia and assessing overall hematologic status 1

• Iron status (ferritin): Critical given that 38-46% of coeliac patients have iron deficiency at diagnosis, and monitoring ensures adequate stores 1, 2, 3

• Folate: Deficiency occurs in 20-22% of newly diagnosed patients and should be monitored routinely 1, 2, 3

• Vitamin B12: Deficiency is present in 15-41% of untreated coeliac patients (more common than traditionally recognized) and requires routine monitoring 1, 2, 4, 3

• Vitamin D and calcium: Important for bone health assessment given the high prevalence of osteopenia/osteoporosis in coeliac disease 1

• Liver enzymes (AST/ALT): Recommended to screen for associated liver disease 1

Additional Considerations

Tests to Consider Periodically (Not Every Visit)

• Thyroid function (TSH): Check annually or when clinically indicated, as autoimmune thyroid disease is associated with coeliac disease 1

• Glucose: Annual screening for diabetes, particularly given association with type 1 diabetes 1

Important Caveats

Common pitfall: The 2018 research by Spijkerman et al. found that in patients with normal values at diagnosis, the incidence of new asymptomatic coeliac-related deficiencies is only 10 per 1000 patient-years 2. However, the 2024 guidelines still strongly recommend routine monitoring because deficiencies based on initial presentation should guide ongoing surveillance 1.

Critical distinction: While anti-TG2 antibodies are useful for monitoring dietary adherence, their normalization has poor sensitivity for identifying persistent villous atrophy, so negative serology does NOT confirm mucosal healing 1.

What NOT to Routinely Order

• Repeat duodenal biopsy: The 2024 guidelines strongly recommend AGAINST routine re-biopsy in asymptomatic patients on a gluten-free diet 1. Biopsy should only be performed if symptoms persist or recur, typically 12-24 months after diagnosis if indicated 1.

• HLA-DQ2/DQ8 testing: Not useful for monitoring; only relevant for initial diagnosis in specific circumstances 1, 5

Practical Algorithm

For this asymptomatic patient requesting routine six-month monitoring:

1. Order the core panel: Anti-TG2 IgA, CBC, ferritin, folate, B12, vitamin D, calcium, liver enzymes 1

2. Add thyroid function and glucose if not checked in the past year 1

3. Ensure dietitian follow-up is scheduled, as dietary assessment is strongly recommended and performs better than serology alone for adherence monitoring 1

4. Do NOT order repeat endoscopy/biopsy in this asymptomatic patient 1

The evidence consistently shows that nutritional testing should focus on deficiencies commonly observed at diagnosis (iron, folate, B12, vitamin D) with special attention to these parameters during ongoing management 1, 3.