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Canadian gastroenterologists weigh in on new celiac disease guidelines

Update from the American College of Gastroenterology aimed at supporting clinical practice.

The American College of Gastroenterology issued updates for diagnosing and managing celiac disease (CD) at the start of 2023.

These guidelines are routinely followed in Canada, and were last updated 10 years ago. 

“These guidelines are established to support clinical practice and suggest preferable approaches to a typical patient with a particular medical problem based on the currently available published literature,” wrote the authors of the American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. “When exercising clinical judgment, particularly when treatments pose significant risks, healthcare providers should incorporate this guideline in addition to patient-specific medical comorbidities, health status, and preferences to arrive at a patient-centred care approach.”

To update the guidelines, researchers identified key questions that healthcare providers face frequently in the diagnosis, management, and followup of patients with CD. From there, they developed recommendations.

Read: Low-carb diets increase risk of heart disease, diabetes, stroke

Key updates
Dr. Gabor Kandel, gastroenterologist and associate professor of medicine at the University of Toronto, said the guidelines present mostly minor changes to the previous guideline.

“There is some new, not too much, and they do apply to Canada and are worth following,” he said, noting that 1% of Canada’s population have CD.

Both Dr. Kandel and Dr. Ines Pinto Sanchez, associate professor, division of gastroenterology at McMaster University Medical Centre, highlighted three noteworthy new recommendations based on key questions the researchers explored:

1. Should a combination of blood tests and small intestine biopsy be used to confirm the diagnosis of celiac disease in children and adults? 

The new guideline calls for bloodwork followed by biopsy to confirm diagnosis. In selected children who meet specific criteria as well as in adults who can’t tolerate an endoscopy, a non-biopsy approach is possible.

“Regarding the diagnosis of celiac disease in adults, there is controversy on whether a duodenal biopsy is needed,” said Dr. Sanchez. “The guidelines recommend biopsies can be avoided under specific circumstances when celiac blood markers—tissue transglutaminase antibody—are highly elevated more than 10 times above the normal limit, which defines celiac as likely.”

Added Dr. Kandel: “For diagnosis, serum IgA transglutaminase serology has a significant false negative rate, but few false positives, provided serum IgA levels are normal. Children with symptoms plus serum IgA transglutaminase serology greater than 10 times normal plus elevated endomysial antibody serology can be definitively diagnosed without small bowel biopsy. All others should have a gastroscopy for a confirmatory duodenal biopsy.”

2. In existing celiac patients, should a followup biopsy be performed two years after initial diagnosis? 

Yes. The guidelines note that the endpoint of gluten-free diet therapy is intestinal healing.

“Follow-up biopsy after dietary gluten restriction for about two years is suggested, irrespective of improvement in symptoms, chiefly because intestinal healing has been described to lower the risk of complications, morbidity and mortality,” said Dr. Kandel.

3. Should gluten detection devices be part of a patient’s standard care?

The update says no.

“Guideline authors recommend not using technology devices to test gluten in food or samples until there is more evidence that their use will be effective to improve adherence to the gluten-free diet,” said Dr. Sanchez.

“In terms of a gluten-free diet, the authors recommend the consumption of gluten-free oats, recognizing that gluten contamination of oats, variable toxicity in different varieties of oats, and the small risk for an immune reaction to the oat protein avenin requires monitoring for oat tolerance. This highlights the importance of continuing research in this area.”

The guideline also recommends the pneumococcal vaccine to prevent infection in those with CD and using case finding to increase detection of CD in clinical practice. The use of mass screening for CD in the community is not recommended.

Read: Canadians with celiac disease especially hard hit by grocery price pain, group says

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