Guidelines re CD

[kickingfrog]

NICE issues guidance on the recognition and assessment of coeliac disease


Posted by Cath on 27/5/2009

GF board



Hi All
This is hot off the press today - haven't read it yet but thought it would be of interest to everyone.

See link:


www.nice.org.uk/nicemedia/pdf/CG86FullGuideline.pdf

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GPs and coeliac disease- British Medical Journal article

Posted by Anon GP on 27/2/2009

GF board

Hello,

I am a GP who regularly reads this board for my own interest(because of coeliacs in family) and I wanted to post something about GPs and diagnosing. I know alot of people have had difficulty getting diagnoses and sometimes it seems to me that people can be quite quick to criticise GPs (though I appreciate the need to let off steam and am also the first to acknowledge there are some really awful GPs out there)
I just wanted to say that from my point of view the comments can sometimes seem a little harsh. Up until recently coeliac disease has been very poorly taught in med school and when it has been mentioned it is cast as a rarity. Irritable bowel syndrome is more common by far (probably 25% of people or more get this at some point) and therefore GPs tend to focus on this and ruling our serious conditions such as cancer.

My own experience is one of CD being fairly peripheral in my consciousness. I did not (nor did my husband -also a GP) even recognise the signs in my own family member and their diagnosis was undoubtedly delayed too.

However, this is a training and education issue- GPs are often dealing with such a variety of things that to recognise what has been taught as a rare condition on first, or maybe even second go is maybe quite unusual. (I know some have had longer battles than this- more questionable practice I would say). Try and give your GP a break- we're often trying our best....

On a brighter note the establishment is addressing the education of coeliac disease and this is the main reason for my post. Recent NICE guidelines out for consultation have already been discussed but today the British Medical Journal (bmj.com) started a new series for GPs named "easily missed" which aims to raise awareness of certain conditions. The very first article in the series is on coeliac disease- with a good education article followed by two excellent patient journeys- one adult, one child. They are well written and easy to read adn since this journal goes out to every registered doctor in the UK and many more abroad, it is a fabulous way of spreading the news about the underestimated prevalence of CD, how to diagnose, and what its really like to live with it. Obviously not everyone will read it but hopefully it will make a difference to all of our experiences in the surgery!!

Just a footnote- As I mentioned the article is in a series named "easily missed" and I think this emphasises how aware most GPs- good and bad- are of CD. The title reflects how we are taught (and this is changing) so try and give us a little leeway.....

hope you understand my plea, its sometimes depressing to be trying your best and getting stick for it,

Struggling to know everything but trying hard GP.



www.bmj.com/content/338/bmj.a3058.extract

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[kickingfrog]

Clinical Practice

Guidelines

Interim Guidelines for the Management of Patients with Coeliac Disease.


Revised by Professor P Ciclitira April 2002

Summary
Coeliac disease is a life-long inflammatory condition of the gastrointestinal tract that affects the small intestine in genetically susceptible individuals. A small intestinal biopsy is mandatory to confirm the diagnosis. Treatment involves a strict gluten-free diet that excludes wheat, rye and barley which should be supervised by a dietician. The role of oats is controversial. Follow-up is important because of potential long-term complications.
Coeliac disease (CD) may be defined as an inflammatory condition of the small intestinal mucosa, that is most marked proximally, and which improves morphologically when gluten is removed from the diet. The disorder may alternatively be termed gluten-sensitive enteropathy or non-tropical sprue. Recent evidence suggests CD has a UK prevalence of 1:300; approximately 150 patients at any one time are cared for in an average District General Hospital. There is considerable under-recognition of the condition which increased use of serological screening should correct. This particularly applies in patients presenting to General Practitioners with either lethargy, anaemia or symptoms of irritable bowel syndrome. Dermatitis herpetiformis (DH) is a related disorder in which there is an itchy blistering skin eruption that frequently affects the knees, elbows, buttocks and back. Confirmation of a diagnosis of DH includes the finding of granular IgA at the dermo-epidermal junction of uninvolved skin on biopsy. The majority of patients with DH have a small intestinal enteropathy that improves with gluten withdrawal.
CD presents at all ages with protean manifestations. Patients may present with clinical or haematological features, or may be identified by serological screening of asymptomatic relatives.

www.bsg.org.uk/bsgdisp1.php?id=c ... =1&m=00023


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Guidelines (from CUK)


There are a number of guidelines available on the management of people with coeliac diseasefor both adults and children.

Adults
The British Society of Gastroenterology (BSG) has recently produced a review paper on the management of coeliac disease in adults. This is not a published guideline but can be viewed on the BSG website.
British Society of Gastroenterology (BSG, 2010) The management of adults with coeliac disease.
Other management guidelines include:
Primary Care Society of Gastroenterology (PCSG, 2006) The Management of adults with coeliac disease in primary care.
This document supersedes previous PCSG guidelines on Decision points in the management of adult coeliac disease in primary care (2002) and Follow-up care of adult coeliac disease (2001).
CREST (2006) Guidelines for the diagnosis and management of coeliac disease in adults. These guidelines are specific to Northern Ireland. As of August 2007, CREST is now part of the Guidelines and Audit Implementation Network (GAIN).

Children
Coeliac working group of the British Society of Paediatric Gastroenterology Hepatology and Nutrition (BSPGHAN, 2006). Guideline for the diagnosis and management of coeliac disease in children.
The BSPGHAN guidelines were derived from the available evidence (including the North American Paediatric guidelines document) after discussion and debate between members of the Managed Clinical Network for Paediatric Gastroenterology. It represents the views of the network members only.
Dermatitis Herpetiformis
Caproni M, Antiga E, Melani L, Fabbri P. (2009) Guidelines for the diagnosis and treatment of DH. Journal of European Academy of Dermatology and Venereology 23 (6): 633 – 638
Osteoporosis
British Society of Gastroenterology (BSG, 2007) Guidelines for osteoporosis in coeliac disease and inflammatory bowel disease
More information on osteoporosis can be found on the management of osteoporosis page.
Prescriptions
Guidelines are available to assist GPs, dietitians, pharmacists and practice nurses in the decision making process when prescribing gluten-freefoods.
Gluten-free foods: a prescribing guide was developed by the British Dietetic Association (BDA), the Primary Care Society for Gastroenterology (PCSG), and Coeliac UK in 2004.
More information on prescriptions can be found on our prescriptions page.
Diagnosis
There is a National Institute for Health and Clinical Excellence (NICE) guideline on the recognition and assessment of coeliac disease which was published in May 2009. This provides information on the clinical signs, symptoms and presentation of coeliac disease. There is currently no NICE guideline on the management of coeliac disease.
Other NICE guidelines that mention coeliac disease include:
Irritable bowel syndrome in adults. Diagnosis and management of irritable bowel syndrome in primary care. This guideline was published in February 2008. It recommends that people who meet the IBS diagnostic criteria should have antibody testing (tissue transglutaminase (tTG) and/or Endomysial antibodies(EMA)) to exclude a diagnosis of coeliac disease.
Constipation in children and young people. Diagnosis and management of idiopathic childhood constipation in primary and secondary care. This guideline was published in May 2010. It recommends testing for coeliac disease in children with evidence of intractable constipation and/or faltering growth.

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines for the diagnosis of coeliac disease are currently being updated.



www.coeliac.org.uk/healthcare-professionals/management-of-coeliac-disease/management-guidelines

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[kickingfrog]

Coeliac disease: recognition and assessment of coeliac disease



www.nice.org.uk/nicemedia/pdf/CoeliacDiseaseFullGuidelinev22DraftForConsultation.pdf

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[kickingfrog]

Improving Diagnosis and Management of Adult Coeliac Disease.



Coeliac Disease: Key facts for busy GPs
· It is estimated that 1 in 300 (now known to be 1 in 100) people may have coeliac disease.
· It can present at any age, peak incidence in the fifth decade.
· 50% of adults present with non gastro-intestinal symptoms such as mild anaemia or tiredness
· Untreated coeliac disease carries an increased risk of intestinal lymphoma and osteoporosis
· Endomysial antibody tests are available to GPs to screen patients with suggestive symptoms.

Most GPs will have between 2 and 6 patients with coeliac disease. It is estimated that two thirds of these remain un-diagnosed. Many of those patients diagnosed will have been discharged from hospital care, and so their GP will often be responsible for providing ongoing care. In recent years there has been developments in the diagnosis and management of coeliac disease that help GPs improve the care of coeliac patients.
Definition.
Coeliac disease is a permanent condition in which the surface of the small intestine is damaged by eating gluten. Gluten is the common name for a protein found in wheat, rye, barley and probably oats
Prevalence.
Screening studies of the general population using the endomysial antibody test suggest that one in 300 people may have coeliac disease. A recent study found that under-diagnosis and mis-diagnosis is common in general practice, and that it is easily missed unless there is a high index of suspicion.
Clinical presentation.
It is helpful to look at the different age groups as they tend to present with different symptoms and signs.
Infants:
· Chronic diarrhoea
· Poor weight gain
· Abdominal distension
· Poor appetite
· Muscle wasting Children :
· Diarrhoea or constipation
· Poor appetite
· Poor growth
· Anaemia Adults:
· Diarrhoea, weight loss and weakness
· Anaemia
· Fatigue

50% of adults now presenting with coeliac disease have minimal or atypical symptoms such as anaemia or chronic fatigue.
GP Investigation.
Recent research has shown that many patients with coeliac disease present to their general practitioners with anaemia or tiredness.
GPs should consider testing people for endomysial antibodies where they have a high index of suspicion of coeliac disease. Endomysial antibodies are usually raised in active coeliac disease. Estimates of the sensitivity and specificity of endomysial antibodies are high[ approaching 100%], and it is widely regarded as the best antibody test for coeliac disease. A positive endomysial antibody is very suggestive of coeliac disease and GPs should refer the patient to the gastroenterologist for a small intestine biopsy to confirm diagnosis. As there is a small possibility of false negatives, patients with negative antibodies in whom the clinical index of suspicion remains high should also be referred for small bowel biopsy. The cost of the test is about £10.
A low haemoglobin, ferritin and folate will support the diagnosis of malabsorption
Referral to the gastroenterology department
Any patient with a positive endomysial antibody test is likely to have coeliac disease, and should be referred for further assessment by the gastroenterologist. Many patients with confirmed coeliac disease are discharged from hospital care once they are symptom free on their gluten free diet. A possible long term complication of coeliac disease is small bowel lymphoma, which is commoner in patients diagnosed later in life .If coeliac patients present to you with unexplained weight loss, unexplained abdominal pain, diarrhoea or rectal bleeding on established therapy a referral to the gastroenterologist is indicated.
Management by GPs.
· Patients with coeliac disease must follow a life long gluten free diet. This usually results in rapid improvement in the patients' symptoms and the abnormality in the small intestine.
· If properly treated, the great majority of coeliac patients should be able to lead full, active and normal lives.
· All newly diagnosed patients should be seen by a dietician, who will take a detailed dietary history and advise on appropriate diet.
· Dietary compliance has been found to be increased if patients join a local branch of The Coeliac Society.
· For the first 6 months of starting the gluten free diet patient may require iron ,folate calcium and vitamin D supplements to correct an existing deficiency.
Follow up care
· Twenty to fifty per cent of diagnosed coeliac patients fail to keep to a strict gluten-free diet.
· Compliance with the gluten free diet has been shown to improve with medical follow up.
· Guidelines on the management of coeliac suggest patients be reviewed at least annually.
· An audit of the follow up care of coeliac patients at my practice found that two thirds of patients had no follow up.
· We have organised a clinic to review our coeliac patients each year.
PCSG Follow up care guidelines.
The Primary Care Society for Gastroenterology has prepared a set of simple, easy-to-use guidelines to help healthcare professionals with responsibility for the follow-up care of patients with coeliac disease.
The document - "../FollowupCoeliac2001.htm" - highlights the key facts about coeliac disease and stresses the importance and how to organise follow-up. The document goes on to explain how often patients should be reviewed, what checks should be carried out at annual assessment and useful sources of information.
The document was produced by a Primary Care Society for Gastroenterology working group and included healthcare professionals from dedicated areas of expertise.
The document is available on the PCSG web-site www.pcsg.org.uk
Dr Sohail Butt is a GP with an interest in coeliac disease in Ashford, Middlesex email [e-mail]
Summer 2001
© PCSG 2002


www.pcsg.org.uk/



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Guidelines on CD Follow-ups


Here are the notes on followup by Dr. Cynthia Rudert at the Gluten Intolerance Group Conference ...... These notes were taken by Janet Rinehart, Houston's Support group coordinator and former CSA president, and verified by Dr. Rudert.

Follow-up Routine Tests
¥ Bone density tests (DEXA) for everyone. Sixty to 80% of adults at time of CD diagnosis have an abnormal density, indicating some bone loss or Osteoporosis.
Get a bone density test to use as a baseline for further tests and to determine about calcium & vitamin D replacement or whether they are candidates for other medications to prevent continued bone loss.
¥ Check Vitamin B-12 level.
¥ TSH (Thyroid Stimulating Hormone) Ñ this test monitors the function of the thyroid
¥ Iron level
¥ Carotene level. If this test is low, you may still be malabsorbing.
¥ RBC folate test. If you are planning to get pregnant, take folate or folic acid before you get pregnant.
¥ CBC (Complete Blood Count) and Complete Metabolic Panel.
¥ ANA Ð nonspecific antibody (may be elevated in CD & other autoimmune disorders)
¥ On a gluten-free diet, all malabsorption conditions should improve.

Monitoring
¥ In the first month after going on a GF diet, the person's GI symptoms should diminish somewhat.
¥ In 3 to 6 months, there should be correction of nutritional deficiencies and the patient should feel the improvement.
¥ Within 6 months, the serologic tests should show a reduction in celiac antibodies.
¥ At 1 year, a follow-up biopsy might be necessary in certain individuals who are not doing as well as expected.
¥ Have regular celiac serological tests every year to test for compliance on your GF diet.

(From Janet on Delphi)

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Guidelines for the Diagnosis and Management of Coeliac Disease in Adults

Coeliac disease affects around 1% of the Northern Ireland population. Although there have been major advances in our understanding of coeliac disease over the last ten years these have not been communicated effectively to healthcare professionals. Patient surveys indicate that coeliac disease is frequently unrecognised, resulting in delayed diagnosis or misdiagnosis, unnecessary or repeated investigations and consultations, and persisting ill-health with risk of complications in the longer term.
Even after diagnosis, there is wide variation in management and follow-up. Increased awareness of the condition, in conjunction with improved diagnostic methods, will have a significant impact on this common condition.

Under the auspices of the Clinical Resource Efficiency Support Team (CREST), a sub-group chaired by Dr William Dickey, Consultant Gastroenterologist, Altnagelvin Hospital, comprising health care professionals from varied backgrounds, was established to produce guidelines on the Diagnosis and Management of Coeliac Disease in Adults

The CREST guidelines on the Diagnosis and Management of Coeliac Disease in Adults were launched at a half-day conference, on Friday 12th May 2006, at the Tullyglass House Hotel, Ballymena. Approximately 100 delegates from the various specialties involved in the management of Coeliac Disease attended the conference.

CREST would like to thank Dr William Dickey, the members of the sub-group and all those who contributed in any way to the production of these guidelines.....

www.gain-ni.org/images/Uploads/Guidelines/CREST%20A3%20Wall%20Chart.pdf

[kickingfrog]

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Pneumococcal vaccination

DATA SHEET

Pneumovax II (Pneumococcal Vaccine, Polyvalent)

PRESENTATION

Single-dose vial containing, in 0.5 ml, 25 mcg of each polysaccharide type derived from capsules of the 23 most prevalent pneumococci dissolved in isotonic saline containing 0.25% phenol.

www.whale.to/vaccines/pneumococcal.html

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Initial Assessment and Follow-up Care of Celiac Patients

Peter Green, M.D.

Gastroenterologist and Director of the GI Endoscopy Unit
Columbia-Presbyterian Medical Center, New York City

At diagnosis, patients should get a Pneumovax, because it is very common for Celiacs to have poor splenic function, which puts them at risk of developing certain bacterial infections such as pneumoccal pneumonia and meningitis.

www.enabling.org/ia/celiac/medcare.html

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Immunizations - pneumococcal vaccine

People at high risk of pneumococcal disease

People of all ages with the following conditions are considered to be at high risk of pneumococcal disease:
Asplenia or dysfunction of the spleen:
Includes conditions such as homozygous sickle-cell disease, and coeliac disease,
……

…..children and adults at high risk of pneumococcal pneumonia, pneumococcal bacteraemia, and pneumococcal meningitis

www.cks.nhs.uk/immunizations_pneumococcal/management/scenario_adults_and_older_children/who_should_receive_the_vaccination/people_at_high_risk_of_pneumococcal_disease


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gut.bmj.com/content/50/suppl_2/a89.full


CD and pneumococcal vaccination

news.bbc.co.uk/1/low/health/365149.stm

Millions at risk from deadly bug

People most at risk are those with chronic heart, lung, liver or kidney disease, diabetes mellitus, severe dysfunctioning of the spleen, sickle cell disease, coeliac syndrome and reduced functioning of the immune system.
Since 1996, the Department of Health has recommended vaccination for all those who are in any at risk group.
However, research shows that up to 50% of GP practices may not be routinely prescribing pneumococcal vaccination to patients.

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From DoH


Pneumococcal disease

What is Pneumococcal Disease?

The disease is caused by the bacterium Streptococcus pneumoniae which is often referred to as the pneumococcus or pneumo bug. It is a leading cause of illness and death throughout the world. It tends to affect the very young, the elderly, those with an absent or non-functioning spleen and those with an impaired immune system. Pneumococcal pneumonia is a serious and widespread disease that can be fatal. It is a difficult disease to diagnose and to treat, especially since antibiotic resistance is emerging. The pneumococcus is also a frequent cause of septicaemia (blood poisoning) and bacterial meningitis (inflammation of the outer layer of the brain).


Prevention
Pneumococcal disease is a serious disease which can be prevented by vaccination.
This vaccination is the subject of recommendations of the Department of Health.



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refs on Pneumococcal vaccination for CD and hyposplenism

Posted by Charlotte, Oxford on 13/5/2005

GF board

.... I thought the comments from some of the clinicians at the RSM somewhat misleading and complacent.
This review on vaccination for coeliacs is particularly relevant:

HYPOSPLENISM IN COELIAC DISEASE: IS PROPHYLAXIS NECESSARY?

N.C. Direkze, N.I. McNeil. Ealing Hospital NHS Trust, Uxbridge Road, Southall UB1 3HW, UK

gut.bmj.com/content/50/suppl_2/a89.full


"Background: It is recognised that coeliac disease and ulcerative colitis are associated with hyposplenism. Pneumococcal prophylaxis for these patients is not normal practice at our hospital but despite this personal experience suggests that coeliac patients rarely suffer from severe infections. However, a recent Drugs and Therapeutics Bulletin suggested that these patients should be vaccinated to reduce the risk of pneumococcal sepsis. Therefore we decided to assess the current practice of gastroenterologists in the UK.

Method: A questionnaire was posted to 292 UK gastroenterologists, three months later the results were collated and analysed.

Results: There was a 78% response rate (n=229).
Coeliac disease: Only 25 (11%) of respondents prescribe pneumococcal prophylaxis for hyposplenism in coeliac disease.
Of these 25, the majority (17) use pneumovax.
To select patients for treatment 22 respondents use haematological indices, two others use ultrasound for this purpose. Of the 229 who responded 9% (n=18) had encountered severe infections in coeliac patients and reported a total 36 severe infections.
Severe pneumococcal sepsis, refractory pneumonia and coexisting immunocompromise were commented on as distinguishing features.
Ulcerative colitis: 6% (n=13) of respondents assess ulcerative colitis patients for hyposplenism.
Five of these do not treat this hyposplenism. If treated these patients receive pneumovax alone (4) or a mixture of pneumovax and long-term penicillin (2)

Conclusion: Despite the suggestions of the Drugs and Therapeutics Bulletin and the British Haematology Guidelines, our findings suggest that current practice is not to assess or treat coeliac patients for hyposplenism in the UK.
As severe pneumococcal disease has been encountered, we believe that gastroenterologists should reassess this practice and produce guidance for these patients."

Incidently “many studies have reported decreased spleen size (hyposplenism) in adults with celiac disease”.
“Patients with coeliac disease invariably have a degree of hyposplenism and may be immunised with pneumococcal vaccine” (BSG guidelines)
….
“Hyposplenism is a common complication of adult celiac disease. A study of splenic function in 17 adult patients with celiac disease was performed both before and during treatment with a gluten-free diet. Splenic hypofunction was assessed evaluating morphological changes in red cells (Howell-Jolly bodies, spherocytosis, achantocytosis). The hyposplenic changes were compared with: age of patients, duration of symptoms previous to diagnosis, severity of the clinical picture and histological response to treatment. We concluded that 82.4% of patients had hyposplenic changes and that there was a non significant tendency to improve such changes by a strict adherence to gluten-free diet.”

“Underactive or absent spleen
The spleen is one of the major sites for destroying platelets and if it is removed the platelet count usually increases. The increase may remain for a long time but usually it settles back into the normal range. In some conditions the spleen is present but either it does not function properly (for example in some patients with Coeliac disease) or it is shrunken (for example in sickle cell disease) and the platelet count is sometimes elevated in these conditions. In this case examination of blood cells under a microscope may reveal characteristic changes suggesting impaired function of the spleen.”

…….

More on hyposplenism here:
www.patient.co.uk/showdoc/40024811/

(Interestingly, my own platelet count was very high when I used to do platelet donation before CD diagnosis. It has since fallen).


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Immunisations for coeliac patients


Individuals with Coeliac Disease have a risk of immunosuppression due to splenic
dysfunction. This is believed to be the case for approximately 25% of patients; however it is
not possible to identify which ones are at risk. It is therefore recommended that all patients
with Coeliac Disease are vaccinated against:


Influenza

Pneumococcus

Haemophilus influenzae type b

Meningococcal group c

(PCSG 2006, British National Formulary, and Immunisation against infectious disease
- 'The Green Book' 2006).

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[kickingfrog]

Care of Patients with Gastrointestinal Disorders (BSG)

BSG

Care of Patients
with Gastrointestinal Disorders
in the United Kingdom
A Strategy for the Future


....Coeliac disease has a true prevalence of 1% of the UK population with much of this
unidentified. This prevalence is the second highest in Europe.As a lifelong condition,
patient self management is important in conjunction with primary care and with
secondary care for initial diagnosis and treatment. Access to dietetic support is
imperative and clinics specialising in Coeliac disease should have this as an integral part
of the service. Bone density measurement is recommended in all patients.
As for other chronic disease areas, involvement of patient support groups is critical to
successful management.




www.bsg.org.uk/pdf_word_docs/strategy06_final.pdf

[kickingfrog]

Guideline - CD in children

GUIDELINE FOR THE DIAGNOSIS AND MANAGEMENT OF COELIAC
DISEASE IN CHILDREN

Coeliac Working Group of BSPGHAN

This guideline is based on the NASPGHAN Celiac Guideline of 2005 (See References), by kind
permission www.naspghan.org and the original guideline from the Welsh Gastroenterology
MCN, to whom we are grateful for allowing us to use their template document......
......
‘Coeliac Disease (CD) is a reversible immune-mediated enteropathy caused by a
permanent sensitivity to gluten in wheat, and related proteins in barley and rye, in
genetically susceptible individuals’.


bspghan.org.uk/document/coeliac/BSPGHANcoeliacguidelinesFINAL.pdf

[kickingfrog]

Annual hospital check for CD (check-ups)

Re: Annual Hospital Check

Posted by Charlotte, Oxford on 1/2/2005
GF board

The best info for coeliac patients and their doctors is in the UK is the Primary Care Society for Gastroenterology website (part of the NHS). Go to link below and search for "coeliac disease" until you come to Coeliac Disease (General) Article (2004).
It includes the following:

"What should be done at Annual Assessments?

Disease status:
Weight, Height, Body Mass Index (D).
Symptom assessment - bowel function (stool frequency, stool consistency, blood in stool) abdominal pain (D).
Investigations: Haemoglobin. Red cell folate. Serum Ferritin. Serum Albumin. Alkaline Phosphatase. Patients with coeliac disease who adhere to a gluten-free diet often eat inadequate intakes of folic acid and iron. (B) Low haemoglobin, red cell folate, and serum ferritin may suggest persisting malabsorption warranting further assessment.
Antibody tests can be used to monitor significant dietary gluten ingestion (C).

Disease prevention: Osteoporosis risk assessment and management
DEXA at menopause for women, at 55 years for men, at any age following fragility fracture.
Advise regular physical activity (A), reduce smoking and alcohol consumption (B).
Calcium supplement - if poor dietary intake (A).
Vitamin D supplements - if housebound (A).
HRT and biphosphonates - if osteoporotic (A).
Some degree of splenic atrophy is present in most patients with coeliac disease, and is sufficiently severe to cause peripheral blood changes in about a quarter.
Patients should be considered for:

Vaccination against pneumococcus and Haemophilus influenzae type b (D).
Vaccination against influenza (D).
Guidance about the increased risks attached to tropical infections e.g. malaria (D).
Life long prophylactic antibiotics are not recommended (C).
Medical care: Management of associated medical problems.

Discussion of familial risk if required. First-degree relatives of people with coeliac disease have a 1 in 10 chance of developing the disease, and should be assessed if they develop suggestive symptoms.
Review prescription items.
Self care:

Discuss gluten-free diet compliance and advice.
Discuss membership of Coeliac Society.
Discuss use of the Coeliac Society's Gluten' Free Food and Drink directory.
Dietary advice on weight, macronutrients, calcium, vitamin D, iron and fibre intake as required."



Link: www.pcsg.org.uk/

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[kickingfrog]

Tests after diagnosis.

Jackie Mum of twins on GF board 10/12/2003

They usually do the following tests. Endomysial antibodies, Thyroid function STSH Free T4 serum urea, electrolytes, creatinine, bone profile, Full blood count. Serum folate and ferritin levels TT Glutaminase. The TT glutaminase is a sensitive test and usually remains positive for quite a while. The twins six month tests showed TT Glutaminase positive but by 9 months on the GF diet it reverted to negative. This will give an indication as to whether you are sticking strictly to the diet. For some people it might take much longer for tests to revert to normal. Especially if they have had coeliac undiagnosed for years.

[kickingfrog]

NICE

National Institute for Health and Clinical Excellence


Coeliac disease Guideline Consultation Comments Table
15th January - 12th February 2009

www.nice.org.uk/nicemedia/pdf/CG86StakeholderCommentsTable220509.pdf

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