What is the treatment for coeliac disease?

Treatment of Coeliac Disease

A strict, lifelong gluten-free diet is the only definitive treatment for coeliac disease and must be initiated immediately upon diagnosis. 1, 2

Core Dietary Treatment

• Complete elimination of wheat, rye, and barley proteins is mandatory for life 1, 3
• Pure oats may be acceptable for most patients and can improve nutritional quality, though contamination concerns exist—introduce slowly with monitoring for adverse reactions 1, 2
• Alternative gluten-free grains including buckwheat, amaranth, quinoa, millet, and sorghum should be incorporated to improve nutritional profile 2
• Focus on home-made, natural gluten-free preparations including extra-virgin olive oil, milk, yogurt, plant foods, and fish rich in omega-3 fatty acids 2

Essential Multidisciplinary Management at Diagnosis

Immediate referral to an experienced dietitian is mandatory at diagnosis for nutritional assessment and comprehensive gluten-free diet education 1, 2, 3. This is not optional—the American Gastroenterological Association emphasizes this as essential care.

• Initial education should cover basics and survival skills, with follow-up sessions expanding to more detailed information 1
• Long-term patients require follow-up with the dietitian at least annually 1, 3

Nutritional Assessment and Supplementation

Test for micronutrient deficiencies at diagnosis—malabsorption and the gluten-free diet itself create significant nutritional risks 1, 2, 3:

• Screen for iron, folate, vitamin D, vitamin B12, vitamin B6, zinc, and magnesium deficiencies 1, 3
• The gluten-free diet and commercial gluten-free products are frequently deficient in B vitamins, calcium, vitamin D, iron, zinc, magnesium, and fiber 1, 3
• B vitamins are particularly important as few gluten-free products are fortified 3
• Nutritional supplements are necessary to address deficiencies and prevent complications 1
• Determine bone mineral density to assess for osteoporosis 2

Monitoring and Follow-Up Protocol

Use a combination of clinical history and anti-tissue transglutaminase IgA antibody serology to monitor gluten-free diet adherence every 12 months 1, 2, 3:

• Positive anti-TG2 IgA levels suggest poor dietary adherence or gluten contamination 1
• Critical caveat: Negative serology cannot confirm strict adherence—sensitivity for detecting diet transgressions is only 52-57% 1
• Verify that initial laboratory abnormalities have normalized 1, 3
• Regular follow-up with both physician and dietitian is required 2

Management of Non-Responsive Disease

For patients with persistent symptoms despite apparent gluten-free diet adherence, follow this systematic approach 1, 2:

1. Confirm the accuracy of the original celiac disease diagnosis 1, 3
2. Systematically review the diet for hidden gluten sources with an experienced dietitian, including cross-contamination 1, 3
3. Check serologic testing 2
4. Consider other conditions: microscopic colitis, pancreatic exocrine insufficiency, bacterial overgrowth, and disaccharidase deficiency 2

Expected Benefits of Treatment

• Protection against development of non-Hodgkin's lymphoma 2
• Improvement in nutritional parameters 2
• Increased bone mineral density, with greatest improvements in first years of treatment 2

Critical Pitfalls to Avoid

• Never initiate a gluten-free diet before completing diagnostic testing—this leads to false-negative serologic and histologic results 1, 3
• Failure to address nutritional deficiencies can delay or prevent symptom resolution in both intestinal and neuropsychiatric manifestations 1, 3
• Do not rely on negative serology alone to confirm strict dietary adherence 1
• Do not assume the gluten-free diet is automatically nutritionally adequate—active monitoring and supplementation are required 1
• Monitor for overweight/obesity as frequency has increased among celiac patients on gluten-free diet 4

Future Pharmacologic Therapies

While various non-dietary therapies are under investigation targeting gluten degradation, immune response regulation, and intestinal permeability modulation, these remain in clinical trials 5, 6, 7. At present, they may have a complementary role to prevent inadvertent gluten contamination but cannot replace the gluten-free diet 7, 8.