Annual Bloodwork for Established Celiac Disease
For adults with established celiac disease on a gluten-free diet, annual bloodwork should include: anti-tissue transglutaminase IgA (anti-TG2 IgA), complete blood count, iron studies (ferritin, serum iron), folate, vitamin B12, and other micronutrients to assess nutritional status and dietary adherence. 1
Core Annual Laboratory Panel
Celiac-Specific Serology
- Anti-TG2 IgA should be checked annually as the primary marker to assess gluten-free diet adherence 1
- A positive anti-TG2 IgA suggests poor dietary adherence or gluten contamination, though a negative value cannot confirm strict adherence or complete lack of gluten exposure 1
- Importantly, normalization of anti-TG2 IgA should NOT be used as a marker of mucosal recovery, as it has poor sensitivity (52-57%) for identifying persistent villous atrophy 1, 2
Nutritional Assessment Blood Tests
The 2024 Nature Reviews Gastroenterology & Hepatology guidelines strongly recommend annual clinical chemistry analysis including: 1
- Complete blood count (CBC) to screen for anemia, which occurs in approximately 20-25% of celiac patients at diagnosis and can persist if dietary adherence is poor 3, 4
- Iron studies (ferritin, serum iron) since iron deficiency is present in 33% of men and 19% of women with celiac disease, and is the most common cause of anemia (occurring in 78.8% of anemic celiac patients) 3, 4
- Folate levels as folate deficiency occurs in approximately 12-23% of celiac patients 3, 4
- Vitamin B12 levels since B12 deficiency is present in approximately 5-11% of patients 3, 4
- Other micronutrients as clinically indicated to evaluate malabsorption and nutritional status 1
Additional Considerations Based on Risk Factors
Thyroid Function
- While not explicitly mandated annually in the core guidelines provided, thyroid autoimmunity is common in celiac disease, and thyroid function tests (TSH, free T4) should be considered given the approximately 5% risk of autoimmune conditions in celiac patients 5
Liver Function Tests
- Elevated aminotransferases can occur in celiac disease and should be monitored, particularly if abnormal at baseline 6, 5
Bone Health Markers
- Vitamin D and calcium levels should be assessed to ensure adequate intake, as bone mineral density deterioration can occur with poor dietary compliance 1
- DXA scanning is NOT routinely recommended annually but should be considered at diagnosis in patients with additional risk factors for low bone mineral density (e.g., menopause, prolonged malabsorption) 1
Timeline and Monitoring Strategy
The guidelines specify a structured monitoring approach: 1
- 1-4 weeks after diagnosis: Initial dietician interview, questionnaires, anti-TG2 IgA, and blood tests to evaluate global gluten-free diet response
- 6 months: Symptom assessment
- Annually thereafter: Anti-TG2 IgA and blood tests (CBC, iron, folate, B12, micronutrients) with dietician involvement 1, 7
Critical Pitfalls to Avoid
- Do not rely on anti-TG2 IgA normalization alone to assess mucosal healing, as serology has poor sensitivity for detecting persistent villous atrophy 1, 2
- Do not perform routine repeat biopsies in asymptomatic patients with normalized serology; biopsy should be reserved for non-responsive disease or suspected complications 1, 7
- Recognize that anemia in celiac disease is multifactorial: it can result from iron deficiency, folate/B12 deficiency, AND anemia of chronic disease (present in 7.8% of anemic celiac patients), so comprehensive evaluation is necessary 3, 4
- Most patients (81-89%) will normalize hemoglobin within 1-2 years of strict gluten-free diet adherence with appropriate supplementation 3