Management of Coeliac Disease in Primary Care Dr Sanjay Gupta Consultant Gastroenterologist.

Slides:



Advertisements
Similar presentations
Irritable bowel syndrome in adults
Advertisements

Recognition and assessment of coeliac disease Implementing NICE guidance 2009 NICE clinical guideline 86.
Diets of different groups
A.M. Report 5/5/09 Jason Haag, M.D.
Healthier Foods and Special Diets. What Our Bodies need for life Carbohydrates Protein Calcium Vitamin A Vitamin B (Folic Acid) Iron.
Definition. Celiac disease is an immune-mediated enteropathycaused by a permanent sensitivity to gluten in genetically susceptible individuals. It occurs.
Celiac disease Prepared by :Maha Hmeidan nahal.
Dr Nader Ghaderi, GPR. General information First described in ancient Greek by Aretaeus of Cappadocia The word Coeliac was first used in 19 th century.
CELIAC DISEASE Done by Fifunmi Laosebikan Samanth Datta Charles Merigini Tamosa aka Boss King.
Coeliac Disease - Fact File 1 Coeliac disease mainly affects the small intestine (part of the gut). It can occur at any age. Coeliac disease is caused.
Gluten Brenna Kress, Brie Jones, Bre Yarnall, Carrie Ufkes, Stephanie Lawrence-Lujan, Karla Barron.
CWEST.. COELIAC DISEASE What you will learn today. In this CWEST presentation, you will discover what coeliac disease is; the associated conditions with.
Coeliac Disease Eileen Parrott. Very common. We all miss opportunities to diagnose. At least 1% of population. Runs in families. Peak incidence currently.
SCREENING FOR CELIAC DISEASE IN EGYPTIAN CHILDREN SCREENING FOR CELIAC DISEASE IN EGYPTIAN CHILDREN Prof. Dr: Mona Abu Zekry -Professor of Pediatrics Head.
 An autoimmune disease where the protein gluten damages the villi in the small intestine causing malabsorption.  Celiac Disease is a lifelong condition.
Celiac Disease in Primary Care Dustin M Adkins Spring 2007.
Coeliac disease – catering gluten-free Kathryn Miller – Policy, Research & Campaigns team.
Celiac Disease. Recent Prevalence of Celiac Disease 1 in 133 people have CD Prevalent, but under diagnosed – Those not diagnosed have a higher death rate.
Eat to Heal... the Cure is Food!. Overview  Celiac Disease Definition Symptoms and presentations Diagnosis Treatment  The Kogan Celiac Center at Barnabas.
Celiac Disease or Sprue By Clo Mudrik. Celiac disease - Sprue Sprue; Nontropical sprue; Gluten intolerance; Gluten-sensitive enteropathy Celiac disease.
Gluten Free Diet Temi Fadugba. What is Gluten? o Gluten is a protein found in wheat, rye, barley and some oats o Gluten generally contains 75-80% protein.
Vegetarian Diets. Vegetarians do not eat meat Usually eat vegetables, fruit, nuts and grains Sometimes do not eat animal products, such as fish, eggs.
Year 11: Objectives What Understand the principles of healthy eating How Research into the Eatwell plate, 8 tips for healthy eating Why To be able to apply.
1 Meeting Children’s Special Food and Nutrition Needs in Child Nutrition Programs Lesson 5: Managing Celiac Disease.
My Dietary Related Disease that I have chosen is: Coeliac Disease.
Gluten Free Diet Accommodating the Gluten Free Diet in The PCH Setting.
Celiac Disease Provided Courtesy of Nutrition411.com Review Date 11/14 G-0605.
Stratford Chefs School Nutrition Course – Week 10.
Coeliac Disease INSERT PRESENTERS NAME. What is Coeliac disease? Coeliac disease affects approximately 1 in 100 Australians. However 75% currently remain.
Coeliac disease NICE Clinical Guideline 86, May 2009.
A Gluten Free Lifestyle By: Lauren Halperin. Objectives:  What is gluten?  Where is gluten found?  What is the history and origin of gluten?  How.
Coeliac Disease Special Dietary Needs. Coeliac Disease Questions You will be asked to answer a series of exam style questions at the end of the lesson.
Celiac Disease.
© Livestock & Meat Commission for Northern Ireland 2015 Food intolerance and allergy.
© Livestock & Meat Commission for Northern Ireland 2015 Diet through life.
JESSIE BUTTS AMANDA SCHUESSLER Celiac Disease. What is Celiac Disease? Genetically based autoimmune disease  Of all 8 0, only one with a known trigger.
The First MEDICEL Meeting Cairo 30 th April to 1 st May 30 th April to 1 st May Prof. Luigi Greco Dr. Laura Timpone Following ESPGHAN PROTOCOL REVISION.
Celiac Disease Provided Courtesy of RD411.com Where dietitians go for information Review Date 9/10 G-0605.
Coeliac Disease. What is Coeliac disease? Autoimmune Heightened immunological response to ingested GLUTEN In genetically susceptible people.
1 Celiac’s Disease Chloe Bierbower Kelly Lonergon Brittany Pinkos Sarah Steinmetz.
Hyperphosphataemia in chronic kidney disease Support for education and learning for children and young people’s renal services: slide set March 2013 NICE.
Vitamin D deficiency In Saudi Arabia
Gluten and Your Gut’s Good Health
A balanced healthy diet
Nutrition for Health and Social Care
Overview of diet related diseases
Education Phase 3 Diet and health.
Presenting with IBS symptoms, baseline assessment.
Coeliac Screening Program
Nutritional Requirements
Courtney Harris, Hanna Breakspear and Holly Pritchard
Celiac Disease By: Michele Arave CNA certified Diagnosed with Celiac.
Coeliac Disease at ABCD
Overview of diet related diseases
Coeliac disease – catering gluten-free
Malabsorption Syndromes
Barts Health Trust 2WW Colorectal Workshop Dr Angela Wong,
Nutritional and Dietary Needs of Different Groups of People
Gluten Free Diet: Necessity for Celiac Disease By: SkyRoots.
Final exam-120 multiple choice-120 marks
Nutritional Requirements
Lecture 7c 21 October 2016.
Diet, insulin and blood glucose
Why Does It Matter What We Eat?
Section A: Nutrition Topic 1: The relationship between diet and health – major diet-related health issues caused by a poor diet and lifestyle.
Presentation by Hope VanCleve
Type 1 DM and Coeliac Disease Quality Standards Audit
Understanding Coeliac Disease:
Northern Cancer Alliance Colorectal Symptoms Assessment Pathway
Celiac Disease in women
Presentation transcript:

Management of Coeliac Disease in Primary Care Dr Sanjay Gupta Consultant Gastroenterologist

Topics covered Epidemiology of coeliac disease Complications and prognosis Management in primary care Prescriptions

Coeliac disease March 2016 Scenario: Management of confirmed coeliac disease Age from 6 months onwards Management in primary care

How common is it? o The incidence of diagnosed coeliac disease is increasing worldwide. -The prevalence of coeliac disease globally is estimated to be 1% with variations among countries, for example the prevalence of coeliac disease is 2% in Finland and 0.3% in Germany [WGO, 2012]. o Population screening data suggest that the incidence of coeliac disease in the UK is 1 in 100 people [BSPGHAN, 2013]. o Coeliac disease is under-diagnosed, and it is estimated that for every person diagnosed with coeliac disease, seven to eight people remain undiagnosed [Mooney, P. et al., 2014]. o Coeliac disease is approximately twice as common in females than males [Mooney, P. et al., 2014].

Prevalence of coeliac

What are the complications? Common complications of coeliac disease are caused by malabsorption, such as [NICE, 2015]: o Anaemia, due to deficiency of iron, folate, or vitamin B12. o Osteoporosis, due to malabsorption of calcium and/or vitamin D. Other complications include [Lebwohl, B. et al., 2015; NICE, 2015; SIGN, 2015]: o Increased risk of fragility fractures. o Chronic pancreatitis with pancreatic insufficiency. o Hepatobiliary abnormalities such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis. o Splenic dysfunction. o Subfertility. o Bacterial overgrowth. o Lactose intolerance. o Microscopic colitis.

o Malignancy, such as Hodgkin's and non- Hodgkin's lymphoma, small intestinal adenocarcinoma, and pancreatic cancer. o Refractory coeliac disease, which is a rare condition, but carries with it an increased risk of lymphoma and high rates of morbidity and mortality. Children may also have [BSPGHAN, 2013]: o Faltering growth. o Delayed puberty.

What is the prognosis? o The majority of people with confirmed coeliac disease report a rapid clinical improvement after starting a gluten- free diet, however 5–30% will have ongoing symptoms and some (numbers not specified) will still have persisting symptoms after 6 to 12 months [NICE, 2015]. Life expectancy for people with: o Diagnosed coeliac disease, who are adhering to a gluten- free diet, is the same as for the general population [Mooney, P. et al., 2014]. o Coeliac disease (diagnosed or undiagnosed) who are not adhering to a gluten-free diet, may be less than the general population [Lebwohl, B. et al., 2015]. o Refractory disease — is lower than that of the general population, because of the increased incidence of intestinal lymphoma [WGO, 2012].

What are the causes and predisposing factors? Coeliac disease is caused by a heightened immunological response to ingested gluten. The reason for this is not yet known, but predisposing factors have been identified: o Genetic predisposition: There is a close association between coeliac disease and human leukocyte antigens (HLA). Not all people with HLA will develop coeliac disease, however the absence of HLA in a person with suspected coeliac disease means that they do not have, and will never develop, coeliac disease [NICE, 2015]. o People with a first-degree relative with coeliac disease have a 4–17% increased lifetime risk of developing coeliac disease. Of those who are homozygous for HLA DQ2, the estimated risk increases to 26%. The risk is also increased in second-degree relatives, but to a smaller extent and the exact prevalence is not known [Lebwohl, B. et al., 2015].

Immunological factors: o People with other autoimmune conditions such as type 1 diabetes mellitus and autoimmune thyroid disease have an increased risk of developing coeliac disease [NICE, 2015].

Arrange annual review of a person with confirmed coeliac disease and ensure the following is covered: o Ensure the person has received adequate advice and information on coeliac disease and gluten-free diets. o Assess the person's adherence to a nutritious, varied, gluten- free diet. o Review the type and quantity of gluten-free foods that have been prescribed, and adjust the prescription accordingly. o Do not routinely recommend nutritional supplements to prevent nutritional deficiencies, however: o Advise on high-dose folic acid supplementation (5 mg once daily) for women who are pregnant, or who are planning a pregnancy. o Some people may require specific supplements such as calcium and vitamin D if their dietary intake is insufficient.

Assess for symptoms and signs of coeliac disease, its complications and associated conditions: o Ask about gastrointestinal symptoms such as diarrhoea, abdominal pain, and blood in the stools. o Measure body weight, height, and body mass index (BMI) to assess for signs of malnutrition (indicated by weight loss in adults, or faltering growth in children). o Assess and manage osteoporosis risk.

Consider annual blood testing, including: o Coeliac serology to help assess adherence to a gluten-free diet. o Full blood count and ferritin — to screen for anaemia. o Thyroid function tests — to screen for autoimmune thyroiditis. o Liver function tests — to screen for autoimmune hepatitis. o Vitamin D, vitamin B12, red cell folate, and serum calcium — to assess for deficiency. o Electrolytes — to assess for Addison's disease.

If malabsorption, diarrhoea, or other symptoms recur or persist despite strictly adhering to a gluten-free diet, exclude, diagnose, and/or manage alternative conditions, complications, and specific deficiencies. Refer the person to a gastroenterologist (or paediatric gastroenterologist) if there is: o Faltering growth in a child. o Symptoms and signs suggestive of gastrointestinal cancer such as unexplained blood in the stool — refer under the two-week wait rule. o Complications, or persistent symptoms or signs of coeliac disease despite adherence to a gluten-free diet.

Consider referring the person to a dietitian if: o There is difficulty in assessing adherence to a gluten- free diet. o Poor adherence to a gluten-free diet is suspected. Offer immunizations, if indicated, for example for people with splenic dysfunction. For more information see the Public Health England publication of the Green Book: Immunisation against infectious disease. Offer more frequent review if problems arise or if there is a change in clinical needs, for example women who become pregnant.

Assessing adherence to a nutritious, varied, gluten-free diet o The NICE GDG recommended, based on clinical experience and expert opinion, that people with coeliac disease and their family/carers should be aware of, and have access to, gluten-free food prescriptions to support adherence to a gluten-free diet. The NICE GDG did not recommend routine nutritional supplements due to limited evidence for their use in addition to a gluten-free diet. It also identified the risk of overdosing on over- the-counter vitamin D, calcium, and iron. o Women with coeliac disease are at an increased risk of neural tube defects due to the malabsorption of folate. It is therefore advised that they use high-dose folic acid supplementation until week 12 of pregnancy

Considering annual blood testing The NICE GDG did not find sufficient evidence to change the current practice of annual serology monitoring. It recommended that coeliac serology testing may be used to help assess adherence to a gluten-free diet, but the evidence does not indicate a strong or conclusive relationship between serological titres and dietary adherence. Some people will have persistently raised serological titres despite adhering to a gluten-free diet and vice versa. Managing recurrent or persistent symptoms The NICE GDG found strong evidence for possible underlying causes of non-responsive coeliac disease such as, exposure to gluten, irritable bowel syndrome, microscopic colitis, or refractory coeliac disease.

Advise the person with coeliac disease that: o The only effective treatment for coeliac disease is long- term adherence to a gluten-free diet. o It is important to ensure a diet is not only gluten-free but also nutritionally balanced. o A large selection of gluten-free products can be prescribed on the NHS.

They must avoid: o Foods based on wheat (and wheat varieties such as spelt, kamut, semolina, triticale), barley, and rye. These include bread, flour, cakes, pastries, and biscuits. o Foods that contain wheat, barley, or rye as fillers or flavouring (such as sausages, ready meals, soups, sauces, and foods cooked with a bread-based batter). o Foods that can be contaminated with gluten during processing and packaging (such as oats) and items fried in the same oil as used to fry gluten-containing food (such as chips from a chip shop that cooks battered fish). o Dietary items that contain malt, such as most beers. Malting is the process of germinating then drying grain such as barley, wheat, and rye. Malting does not remove all of the gluten.

o They can include pure, uncontaminated oats in their diet. o Many oats and oat-containing products contain small amounts of gluten from barley, wheat, or rye, and these small amounts can be harmful for people with coeliac disease. o In contrast, pure, uncontaminated oats can be eaten by most people with coeliac disease. o People eating a diet containing of gluten-free oats should be monitored regularly.

They should read food labels to check if the products are suitable. o Manufacturers of packaged foods are required by law to list on the product's label any cereal containing gluten that is used as an ingredient, no matter how little is used. o Products using oats as an ingredient must be labelled with 'contains oat gluten', although the protein in oats is avenin. o Food products are suitable for people with coeliac disease if they have the Crossed Grain Symbol, or are labelled 'gluten- free' or 'very low gluten'. o Products containing Codex wheat starch will be labelled as containing wheat or wheat starch, but are suitable for people with coeliac disease. Codex wheat starch is a specially manufactured wheat starch where the gluten in the cereal has been reduced to a trace level.

Helpful information and resources are available online, including: o Coeliac UK — a national charity working for people with coeliac disease and dermatitis herpetiformis, which provides support, information, and advice on how best to cope with a gluten-free diet. o Food Standards Agency — provides information about coeliac disease, gluten-free foods, and their labelling.

How to prescribe o Usually, following diagnosis, a dietitian will discuss the products available on prescription with the person, and will draw up an initial list of choices. o A list of prescribable gluten-free products can be found on the Coeliac UK website. o Allow the person to try a variety of foods before setting up a repeat prescription. A dietitian or pharmacist may be able to advise on manufacturers who have trial packs of a variety of their products. o Changes may be required to accommodate new needs or preferences. o Gluten-free products are allocated unit values based on their carbohydrate and energy content, and their cost. There is a recommended quantity to prescribe for various patient groups. (Coeliac UK, 2011)

Quantity to prescribe o Each prescription should be for a 1-month supply of gluten- free foods. o Gluten-free items are allocated unit values based on their carbohydrate and energy content, and their cost. For example:  400 g bread, rolls, or baguettes — 1 unit.  500 g of flour/cake/bread and pastry mix — 2 units.  100 g biscuits/crackers — 0.5 units.  250 g of pasta — 1 unit.  One 110–180 g pizza base — 0.5 units. o Base the quantity of products on the person's age, gender, activity level, and nutritional needs. o See the tables for children, women and men for examples of minimum monthly prescriptions of gluten-free products.

Conclusions NICE guidelines March 2016 have outlined details of annual follow-up in primary care including details of prescriptions Referral to secondary care should be done for patients whose symptoms are not controlled on GF diet No recommendations on who should follow-up

Thank you Any questions?