Treatment of Celiac Disease
No treatment is curative for celiac disease; however, the most effective management strategy is to follow a 100% gluten-free diet.3,11 This treatment can pose significant challenges, including but not limited to inconsistency of food labels; risk of cross-contamination in food products, such as oats; and restriction of social events. Despite their best efforts, many patients struggle to maintain a consistently gluten-free diet, leading to continued symptoms and decreased quality of life.
These persistent intestinal symptoms can closely resemble irritable bowel syndrome (IBS), which also is a common comorbidity of celiac disease. Although there is no treatment for IBS, a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet has shown some promise in reducing GI symptoms associated with IBS.18 The low FODMAP diet eliminates short-chain carbohydrates that are poorly absorbed in the small intestine, increasing gas production and fermentation that lead to intestinal disturbances (eg, bloating and diarrhea). Use of a low FODMAP diet also demonstrated efficacy in patients with celiac disease with persistent intestinal symptoms despite being on a gluten-free diet. Research on this topic is limited.18
In addition, many patients with celiac disease may need vitamin supplementation. Because of the inherent malabsorptive nature of the disease, patients can be deficient in vitamin B12, vitamin D, iron, and folic acid.3,11 Given that celiac disease treatment is largely based on diet and proper vitamin supplementation, nutritionists should be included in the management plan.
Celiac disease requires long-term management by clinicians to adequately assess adherence to a gluten-free diet and monitor potential complications of celiac disease. The AGA recommends follow-up serology at 6 and 12 months after diagnosis and annually thereafter to assess dietary adherence.3 A downward trend in serologic values indicates adherence and at least partial healing of mucosal damage.3 Patients with persistent or relapsing symptoms with no known cause should undergo endoscopic biopsy to determine mucosal healing even if TG2-IgA levels are negative.3
Iron-deficiency anemia is the most common type of anemia worldwide19,20 and is a frequent finding in pregnant women because of increased iron requirements by the body or in women with abnormally heavy periods because of increased blood loss. In these patients, oral iron supplementation is generally effective; however, iron supplementation may not correct anemia secondary to an underlying GI pathology, such as malignancy, occult bleeding, or impaired iron absorption.16,19,20 In cases of refractory iron-deficiency anemia, and a GI workup is warranted.16
Of the possible etiologies of refractory iron-deficiency anemia, malabsorptive disorders such as celiac disease should generally be considered at the top of the differential list.19,20 This was demonstrated in a prospective cross-sectional study (N=184) in which positive serologic tests for celiac disease were more common among children with refractory iron-deficiency anemia (28.9%) than in children with treated iron-deficiency anemia (5.4%) or healthy children (2.1%; P <.001).19 The recent 2020 AGA guidelines on this topic recommend that patients with refractory iron-deficiency anemia should be screened for celiac disease with serologic testing.16,19,20
MR initially presented for complaints of thinning hair. A workup eventually revealed iron-deficiency anemia for which she was treated unsuccessfully with iron supplementation for 3 years. Lingering symptoms and treatment failure prompted consideration of a celiac disease diagnosis. Although MR did experience mild GI symptoms, she only mentioned these symptoms after prompting by the provider during the complete history and physical. She was fortunate to receive an accurate diagnosis and appropriate therapy at an early age as most patients with celiac disease experience a delay in diagnosis because of the extremely varied manifestations of the disease and lack of provider awareness. Therefore, it is important for providers to recognize both the classic and nonclassic presentations of celiac disease to effectively diagnose patients.
Jessica Austel, PA-S, is a student at Augusta University. Alicia Elam, PharmD, is an associate professor, Physician Assistant Department, Augusta University, Augusta, Georgia.
1. Coutts A. An overview of coeliac disease: patterns, causes, symptoms, and management. Gastrointest Nursing. 2013;11(3):26-30. doi.org/10.12968/gasn.2013.11.3.26
2. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012;107(10):1538-1544. doi: 10.1038/ajg.2012.219
3. Husby S, Murray JA, Katzka DA. AGA clinical practice update on diagnosis and monitoring of celiac disease-changing utility of serology and histologic measures: Expert review. Gastroenterology. 2019;156(4):885‐889. doi: 10.1053/j.gastro.2018.12.010
4. Oxentenko AS, Rubio-Tapia A. Celiac disease. Mayo Clin Proc. 2019;94(12):2556-2571. doi: 10.1016/j.mayocp.2019.02.019.
5. Ludvigsson JF, Rubio-Tapia A, van Dyke CT, Melton LJ 3rd, Zinsmeister AR, Lahr BD, Murray JA. Increasing incidence of celiac disease in a North American population. Am J Gastroenterol. 2013;108(5):818-824. doi: 10.1038/ajg.2013.60
6. Parzanese I, Qehajaj D, Patrinicola F, et al. Celiac disease: from pathophysiology to treatment. World J Gastrointest Pathophysiol. 2017;8(2):27-38. doi: 10.4291/wjgp.v8.i2.27
7. Mazzilli MC, Ferrante P, Mariani P, et al. A study of Italian pediatric celiac disease patients confirms that the primary HLA association is to the DQ(alpha 1*0501, beta 1*0201) heterodimer. Hum Immunol. 1992;33(2):133-9. doi: 10.1016/0198-8859(92)90064-t
8. Nellikkal SS, Hafed Y, Larson JJ, Murray JA, Absah I. High Prevalence of celiac disease among screened first-degree relatives. Mayo Clin Proc. 2019;94(9):1807-1813. doi: 10.1016/j.mayocp.2019.03.027
9. Gaylord A, Trasande L, Kannan K, Thomas KM, Lee S, Liu M, Levine J. Persistent organic pollutant exposure and celiac disease: a pilot study. Environ Res. 2020;186:109439. doi: 10.1016/j.envres.2020.109439
10. Andrén Aronsson C, Lee HS, Hård Af Segerstad EM, et al. Association of gluten intake during the first 5 years of life with incidence of celiac disease autoimmunity and celiac disease among children at increased risk. JAMA. 2019;322(6):514-523. doi: 10.1001/jama.2019.10329
11. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA; American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108(5):656‐677. doi: 10.1038/ajg.2013.79
12. Freeman HJ, Chopra A, Clandinin MT, Thomson AB. Recent advances in celiac disease. World J Gastrointest Pathophysiol. 2011;17(18):2259-2272. doi: 10.3748/wjg.v17.i18.2259
13. Paez MA, Gramelspacher AM, Sinacore J, Winterfield L, Venu M. Delay in diagnosis of celiac disease in patients without gastrointestinal complaints. Am J Med. 2017;130(11):1318‐1323. doi: 10.1016/j.amjmed.2017.05.027
14. Laurikka P, Nurminen S, Kivelä L, Kurppa K. Extraintestinal manifestations of celiac disease: early detection for better long-term outcomes. Nutrients. 2018;10(8):1015. doi: 10.3390/nu10081015
15. Sedda S, Caruso R, Marafini I, et al. Pyoderma gangrenosum in refractory celiac disease: a case report. BMC Gastroenterol. 2013;13:162. Published 2013 Nov 27. doi:10.1186/1471-230X-13-162
16. Ko CW, Siddique SM, Patel A, Harris A, Sultan S, Altayar O, Falck-Ytter Y. AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology. 2020;159(3):1085-1094. doi: 10.1053/j.gastro.2020.06.046
17. Husby S, Koletzko S, Korponay-Szabó IR, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr. 2012;54(1):136-160. doi: 10.1097/MPG.0b013e31821a23d0.
18. Roncoroni L, Bascuñán KA, Doneda L, et al. A low FODMAP gluten-free diet improves functional gastrointestinal disorders and overall mental health of celiac disease patients: a randomized controlled trial. Nutrients. 2018;10(8):1023. doi: 10.3390/nu10081023
19. Shahriari M, Honar N, Yousefi A, Javaherizadeh H. Association of potential celiac disease and refractory iron deficiency anemia in children and adolescents. Arq Gastroenterol. 2018;55(1):78-81. doi: 10.1590/S0004-2803.201800000-15
20. Hershko C, Camaschella C. How I treat unexplained refractory iron deficiency anemia. Blood. 2014;123(3):326‐333. doi: 10.1182/blood-2013-10-512624
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