ACG updates, reaffirms guidelines on evaluation, management of patients with celiac disease

The American College of Gastroenterology (ACG) recently published updated recommendations for the evaluation and management of patients with celiac disease.

The guidelines include recommendations on indication for celiac disease testing; diagnostic strategies for patients on a gluten-containing or gluten-free diet; role of biopsy for confirmation of the diagnosis; indication for gluten challenge and genetic testing; general approach to management; preventive care including vaccination; monitoring of gluten-free diet adherence, including discussion of gluten-detection devices, probiotics, goals of therapy, and outcomes; and the differential diagnosis for nonresponsive celiac disease.

The diagnostic approach to celiac disease in adults using serological and histologic data remains unchanged from the 2013 ACG clinical guidelines on diagnosis and management of celiac disease. In addition to grading strength of evidence and strength of recommendation, the updated guidelines allowed for dissent from the majority opinion by one or more authors. They are intended for all clinicians who care for patients with celiac disease and were published Jan. 5 by the American Journal of Gastroenterology.

The recommendations include the following:

• Esophagogastroduodenoscopy with multiple duodenal biopsies is recommended for confirmation of diagnosis in both children and adults with suspicion of celiac disease (strong recommendation, moderate quality of evidence; dissent 1).
• In symptomatic adults unwilling or unable to undergo upper GI endoscopy, a combination of high-level tissue transglutaminase antibody IgA (>10 times the upper limit of normal) with a positive endomysial antibody in a second blood sample are suggested as reliable tests for diagnosis of likely celiac disease (conditional recommendation, moderate quality of evidence; dissent 0).
• Setting a goal of intestinal healing is suggested as an end point of gluten-free diet therapy, as well as individualized discussion of goals of the gluten-free diet with the patient beyond clinical and serological remission (conditional recommendation, low quality of evidence; dissent 0).
• Routine use of gluten detection devices in food or biospecimens is not suggested among patients with celiac disease (conditional recommendation, low quality of evidence; dissent 1).
• There was insufficient evidence to recommend for or against the use of probiotics for the treatment of celiac disease (evidence gap in recommendation, very low quality of evidence; dissent 0).
• Consumption of gluten-free oats is recommended in the diet of those with celiac disease, and gluten contamination, variable toxicity in different varieties of oats, and the small risk for an immune reaction to the oat protein avenin require monitoring for oat tolerance (strong recommendation, moderate quality of evidence; dissent 0).
• Vaccination to prevent pneumococcal disease is suggested in patients with celiac disease (conditional recommendation, low quality of evidence; dissent 0).
• Case finding (i.e., serologic testing for celiac disease in patients with symptoms or conditions closely associated with the disease) is recommended to increase detection of celiac disease in clinical practice (strong recommendation, low quality of evidence; dissent 0).
• Mass screening for celiac disease in the community is not recommended (strong recommendation, low quality of evidence; dissent 0).

“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-centered care approach,” the authors wrote.