From the Guidelines
Screening for coeliac disease should be performed in all patients with type 1 diabetes, starting at diagnosis and repeated every 2-5 years, using serological testing with tissue transglutaminase (tTG) IgA antibodies and total IgA levels, or tTG IgG and deamidated gliadin peptide antibodies if IgA deficient, as recommended by the most recent guidelines 1.
Rationale for Screening
The rationale for screening is the increased prevalence of coeliac disease in type 1 diabetes patients (1.6-16.4% compared to 0.3-1% in the general population) due to shared genetic susceptibility, as noted in multiple studies 1. Early detection and treatment of coeliac disease through a strict gluten-free diet can prevent complications such as malabsorption, growth failure in children, osteoporosis, infertility, and increased risk of malignancy, while potentially improving glycemic control in diabetes.
Screening Recommendations
- Screen youth with type 1 diabetes for celiac disease by measuring IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or IgG tTG and deamidated gliadin antibodies if IgA is deficient, as recommended by the American Diabetes Association 1.
- Repeat screening within 2 years of diabetes diagnosis and then again after 5 years, and consider more frequent screening in youth who have symptoms or a first-degree relative with celiac disease, as suggested by the guidelines 1.
- Individuals with confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a registered dietitian nutritionist experienced in managing both diabetes and celiac disease, as recommended by the guidelines 1.
Importance of Early Detection and Treatment
Early detection and treatment of coeliac disease are crucial to prevent long-term complications and improve quality of life for patients with type 1 diabetes, as highlighted in the studies 1. A gluten-free diet can reduce symptoms, improve growth and weight gain, and potentially improve glycemic control in diabetes, making regular screening and early intervention essential for optimal patient outcomes.
From the Research
Screening Practices for Coeliac Disease in Type 1 Diabetes
- The study 2 investigated screening practices for coeliac disease in patients with type 1 diabetes across North America, finding that 35% of work locations screened for coeliac disease, with endocrine clinics reporting screening at the highest frequency (80%).
- Tissue transglutaminase was the most common screening test used, and the most frequently recommended treatment of confirmed coeliac disease was a gluten-free diet 2.
- However, only 71% of respondents recommended biopsy in patients with positive serologies, indicating a need for increased education regarding coeliac disease in patients with type 1 diabetes 2.
Prevalence of Coeliac Disease in Type 1 Diabetes
- A study 3 found a cumulative prevalence of coeliac disease of 14.6% in children and adolescents with type 1 diabetes, with 83.78% of those with positive IgA-TTG having no recorded gastrointestinal symptoms or coeliac disease-related clinical signs.
- Another study 4 found that the prevalence of coeliac disease in type 1 diabetes in children is 1:6 to 1:103 and in adults 1:16 to 1:76, based on small bowel biopsy diagnosis.
- The study 5 found that 4.4% of patients with type 1 diabetes had IgA antibodies to tissue transglutaminase, indicating silent coeliac disease.
Diagnostic Tests for Coeliac Disease
- The study 6 found that IgA anti-tissue transglutaminase antibodies have high sensitivity and specificity for coeliac disease, and are a valid alternative to anti-endomysial antibodies in screening for suspected coeliac disease.
- The study 5 also found that IgA antibodies to tissue transglutaminase are sensitive serological parameters for detecting silent coeliac disease in patients with type 1 diabetes mellitus.
- However, confirmatory small bowel biopsy remains necessary for diagnosis, as some patients with positive antibodies may be without histological changes 5.
Recommendations for Screening
- The study 4 recommends that screening for coeliac disease should be part of the routine investigation and offered to all patients with type 1 diabetes, due to the high prevalence and potential benefits of treatment with a gluten-free diet.
- The study 3 also emphasizes the importance of screening, given the high prevalence of atypical symptoms and silent coeliac disease in those with type 1 diabetes.