Stat Consult — HLA genetic testing (absence of DQ2 or DQ8 alleles rules out celiac disease) — Upper intestinal endoscopy and distal duodenal biopsy if otherwise warranted • Testing for nutritional deficiencies (hemoglobin, iron, folate, calcium, vitamin D) • Radiographic studies are not necessary for celiac disease, but may be used to rule out other diagnoses. Treatment overview
Additional considerations
• Refer patient to experienced dietitian • Refer patient to support group • In patients with newly diagnosed celiac disease who also have anxiety and depression, adding psychological support when starting a gluten-free diet is associated with lower rates of depression after six months. • Gluten-free camp attendance reported to improve quality of life in children with celiac disease Follow-up
• Monitor patients for improved symptoms in response to a gluten-free diet (expected after six to 12 months) • Monitor dietary compliance • Check bone mineral density to assess for osteoporosis. ■
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• Lifelong gluten-free diet recommended — Avoid all foods containing wheat, rye, and barley gluten — Avoid all foods containing oats and lactose initially — Avoid beers, lagers, ales, and stouts — Other foods that may include gluten include dextrins, malt, and caramel coloring. — Beware of gluten in medications, and in food additives, emulsifiers, and stabilizers. — Wheat flour may be used in many prepared foods including canned products, salad dressings, and ice creams. — Use only rice, corn, maize, buckwheat, potato, soybean, or tapioca flours, meals, or starches. — Look for foods with the gluten-free symbol. — Try wheat starch with gluten removed, oats, and lactose after diagnosis is established. • The amount of gluten that causes symptoms varies among patients with celiac disease.
• Strict adherence to a gluten-free diet for more than five years may reduce risk for non-Hodgkin lymphoma. • Oats in diet appear safe in controlled trials, but some patients may have oat intolerance and commercial oats are often contaminated with gluten. • Treat nutritional deficiencies with special attention to iron, folate, and vitamin B12. • Addition of budesonide to a gluten-free diet may improve symptoms in patients with celiac disease with malabsorption • Limited evidence for immunosuppression therapy (e.g. azathioprine, infl iximab, cyclosporine) for refractory celiac disease
“We laugh, but it’s a mirthless laugh.” 106 THE CLINICAL ADVISOR • DECEMBER 2011 • www.ClinicalAdvisor.com