World Digestive Health Day WDHD – May 29, 2016 MANAGING ADULT CELIAC DISEASE IN THE OUTPATIENT CLINIC, continued folic acid, vitamin B12, vitamin D, and tTgA and that Thyroid function to be checked annually. SYMPTOMS DURING FOLLOW-UP If patients present themselves with low BMI, we try to normalize the BMI between 18.5 - 25, and above 20 for elderly and refractory celiac patients, however at the moment 40% of our newly diagnosed celiac patients are overweight with a BMI over 25 kg/m2.15 In a substantial part of those patients, the weight goes down in the first year after initiation of GFD, not just because the diet is “unpalatable”, but also because some hungry feeling is disappearing. So far studies about the appropriate attitude for this subgroup are lacking. Normally BMI increases on the GFD. On GFD 15-20% of patients move from a normal or low BMI-class into an overweight BMI-class and 20 % of those already overweight at diagnosis gain weight.16 The disappearance of fatigue, especially in females over the age of 30, is one of the most significant problems and goals in daily clinic routine; the proportion of patients who do have a slow response to a gluten-free diet and/or histologic recovery is another topic.1 SCREENING IN CELIAC FAMILIES We observed a high positive screening rate of 10% in both first and second-degree relatives.17 However, there probably was a selection bias; only those relatives with a low threshold for screening were screened. Maybe, this selection of patients in the family already had (albeit minor) complaints. A large multi-center study from the USA showed a rate of only 5% in both first and second-degree relatives.18,19 We suggest that 4-5% reflects the true rate in daily practice appropriately. Patients with a first-degree family member with a confirmed diagnosis of CD should be offered to be tested if they show possible signs or symptoms of CD. We advise offering newly diagnosed celiac patients screening on their first and second family degree family members. Screening should include DQ2/8 typing, tTgA antibodies, hemoglobulin, folic acid, vitamin B12, iron, and Thyroid function. FOLLOW UP AND DIETICIANS Malabsorption, weight-loss, and vitamin/mineral deficiencies characterize classical CD. We recently reported that the majority of patients in an “early diagnosis” adult untreated CD patient group, with non-classical presentation, had serum vitamin and mineral deficiencies at diagnosis.15 A majority of celiac patients were zinc deficient at diagnosis. Based on our experience and supported by others, we suggest monitoring body weight at diagnosis and nutritional serum parameters: at least vitamin B6, folic acid, vitamin B12, zinc, and (25-hydroxy) vitamin D of the fat soluble vitamins. Moreover, we suggest follow-up until serum values are at satisfying levels or upon indication (bone density deviations, chronic or recurrent diarrhea, or zinc related skin lesions). Careful dietetic review once a year was part of the deal in our out clinic. However, the majority of well-educated patients are reluctant to this approach. Therefore, inadvertent gluten intake is discussed during the out-clinic visit, especially in patients with a poor educational state or low-income families. In that case, we check if there is adequate nutrient vitamin and mineral intake. There is a lack of studies about GFD check in different countries.6 We and others have already reported 30 years ago that the dietary adherence is poor in a substantial part of patients.20 In our out-clinic we control around 30-40 patients who do not adhere at all. The majority of those patients normalize the diet to an adequate GFD within five years of follow-up due to an increase in symptoms. Recently an Israeli study reported about pediatric celiac patients who were lost to follow-up.21 This cohort had not only lowered adherence to GFD, but also failed periodic serological monitoring, which left them oblivious to the consequential disease activity status. This is problematic in young patients, who may not reach their growth potential (catch-up growth, etc.) and are still too young to consider the long-term effects of their attitude with an enlarged risk for auto-immune disease in general. Continuation time of mineral and vitamin interval has yet to be determined since patients are at risk for deficiencies even after 10 years of a GFD.22 FOLLOW UP AND DERMATITIS HERPETIFORMIS Dermatitis herpetiformis (DH) is the cutaneous manifestation of gluten-sensitive enteropathy. It is a herpetiform clustering of extremely itchy urticated papules, especially on the extensor side of the elbows and knees, buttocks, and scalp. Improvement of DH with GFD takes several months according to the current literature.23 However, remission can take some years, but is poorly documented in current literature. Diamonodiphenyl sulfone and sulfapyridine are the primary medications to treat DH. Diamonodiphenyl sulfone is almost always indicated and initiated due to rash and the itching. World Digestive Health Day WDHD May 29, 2016 WGO Handbook on DIET AND THE GUT 35
WGO Handbook on Diet and the Gut_2016_Final
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