📋 Key Information Summary
- Coeliac disease affects approximately 1 in 70 Australians, yet ~80% remain undiagnosed; it is a lifelong autoimmune enteropathy triggered by dietary gluten in genetically susceptible individuals (HLA-DQ2/DQ8).
- Test for coeliac disease in patients with chronic diarrhoea, unexplained iron-deficiency anaemia, unintentional weight loss, osteoporosis or osteopenia, unexplained persistent elevation of liver transaminases, and in those with associated autoimmune conditions (type 1 diabetes, autoimmune thyroid disease) or a first-degree family history.
- First-line serology is tissue transglutaminase IgA (tTG-IgA) combined with a total serum IgA level to exclude selective IgA deficiency — do not rely on a single test alone.
- If total IgA is deficient (<0.07 g/L), use deamidated gliadin peptide (DGP) IgG or tTG-IgG as the screening antibody; tTG-IgA will be falsely negative in IgA deficiency.
- Patients must be on a gluten-containing diet (≥2 g gluten/day for ≥6 weeks, ideally equivalent to ≥4 slices of bread daily) prior to serology and biopsy — testing while gluten-free yields false negatives.
- Positive serology requires confirmatory upper GI endoscopy with ≥4 duodenal biopsies (≥2 from the descending duodenum and ≥2 from the duodenal bulb) while the patient continues on gluten.
- Refer to a gastroenterologist for endoscopic confirmation; a Marsh classification ≥2 on histology, combined with positive serology, confirms coeliac disease.
- The only effective treatment is strict lifelong gluten-free diet (GFD), eliminating wheat, barley, rye, and contaminated oats; dietitian-led education is essential and is Medicare-rebated under GP Management Plans.
- Monitor annually: symptom review, tTG-IgA titre (falling titres confirm adherence), iron studies, folate, vitamin B12, vitamin D, calcium, zinc, and bone mineral density (DEXA) at baseline and as indicated.
- Refractory coeliac disease (RCD) — persistent symptoms and villous atrophy despite strict GFD for ≥12 months — warrants specialist re-evaluation, HLA typing, and exclusion of enteropathy-associated T-cell lymphoma.
- Aboriginal and Torres Strait Islander Australians may face barriers to diagnosis and dietary management including remote-living, limited dietitian access, and culturally inappropriate food labelling — proactive screening and supported follow-up are essential.
- Patients with coeliac disease have an increased risk of osteoporosis, enteropathy-associated T-cell lymphoma, small bowel adenocarcinoma, and other autoimmune diseases; long-term surveillance improves outcomes.
Introduction & Australian Epidemiology
Coeliac disease is a chronic immune-mediated enteropathy of the small intestine triggered by the ingestion of gluten (prolamins found in wheat, barley, and rye) in genetically predisposed individuals carrying HLA-DQ2 or HLA-DQ8 haplotypes. It is characterised by villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes in the duodenal mucosa, leading to malabsorption and a wide spectrum of systemic manifestations.
In Australia, population-based screening studies estimate a prevalence of approximately 1 in 70 (≈1.4%) in the general population, though most cases remain undiagnosed. The Australian Coeliac Disease Epidemiology Study and the Busselton Health Study have confirmed that the diagnosed-to-undiagnosed ratio is roughly 1:5 to 1:8. This is consistent with global data showing that only 10–20% of affected individuals are clinically diagnosed.
Coeliac disease can present at any age and is equally prevalent in males and females, although diagnosed cases show a female predominance (~2:1). The median age at diagnosis in Australian adults is 40–50 years, with a second peak in the 60s. Paediatric presentation is most common between 6 months and 2 years, coinciding with the introduction of gluten-containing cereals.
Significant diagnostic delay: The average time from symptom onset to diagnosis in Australian adults is 6–13 years. Many patients are labelled with irritable bowel syndrome (IBS) prior to diagnosis. Maintaining a low threshold for serologic testing in at-risk groups is critical.
The economic burden is substantial. Coeliac disease accounts for direct healthcare costs including specialist consultations, endoscopy, dietitian services, and gluten-free food costs (estimated at an additional AUD ,000–2,000 per year per household). The Australian Government partially subsidises gluten-free products under some state-based schemes, though no federal GST exemption currently applies to gluten-free foods nationally.
Who to Test
Given the high prevalence of undiagnosed coeliac disease in Australia, clinicians should maintain a high index of suspicion. Testing is recommended for the following groups, aligned with the Royal Australian College of General Practitioners (RACGP) and Gastroenterological Society of Australia (GESA) guidance:
Symptomatic Indications for Testing
Common
Gastrointestinal Symptoms
Chronic or recurrent diarrhoea, steatorrhoea, bloating, abdominal pain, nausea, constipation (often overlooked), unexplained flatulence, recurrent aphthous ulcers
Setting: Primary care — serologic screening
Extra-intestinal
Systemic Manifestations
Unexplained iron-deficiency anaemia (IDA), fatigue, unintentional weight loss, failure to thrive (paediatric), dermatitis herpetiformis, unexplained persistent elevation of serum ALT/AST, recurrent miscarriage or infertility, dental enamel defects, short stature
Setting: Primary care — serologic screening + targeted investigations
High-Risk
Associated Conditions & Family History
First-degree relative of a coeliac patient (5–15% risk), type 1 diabetes mellitus (prevalence 3–8%), autoimmune thyroid disease, selective IgA deficiency, Down syndrome, Turner syndrome, Williams syndrome, Sjögren syndrome, primary biliary cholangitis, autoimmune hepatitis
Setting: Primary care — screen at diagnosis of associated condition, then periodically
Additional Indications
- Osteoporosis or osteopenia — especially in young adults or those without other risk factors; coeliac disease is found in up to 3–10% of patients with unexplained low bone mineral density.
- Unexplained raised transaminases — coeliac disease accounts for a proportion of otherwise unexplained chronic transaminitis (prevalence of coeliac disease in this group is 3–9%).
- Irritable bowel syndrome (IBS) — Australian and international data show 4–8% of patients meeting IBS criteria have undiagnosed coeliac disease; GESA recommends excluding coeliac disease before confirming an IBS diagnosis.
- Chronic fatigue — particularly when combined with other suggestive features.
Critical rule — do NOT start a gluten-free diet before testing: Serology and biopsy are only reliable while the patient is consuming gluten (≥2 g/day for ≥6 weeks). Initiating a GFD before diagnostic testing will produce false-negative results and may delay diagnosis by months to years. If the patient has already self-started GFD, a supervised gluten challenge is required before testing.
Population Screening
Routine population screening of asymptomatic individuals is not currently recommended in Australia by GESA or RACGP. However, targeted case-finding in the high-risk groups listed above is strongly endorsed. For first-degree relatives, offer serologic testing at the time of the index case's diagnosis and repeat at intervals (every 2–3 years or if symptoms develop).
Serologic Testing
Serologic testing is the first-line investigation for coeliac disease in both adults and children. The choice of antibody depends on the patient's total IgA status.
Recommended First-Line Antibody Panel
| Test | When to Use | Sensitivity | Specificity | Notes |
|---|---|---|---|---|
| tTG-IgA (tissue transglutaminase IgA) | First-line screening in IgA-sufficient patients | 95–98% | 95–98% | Best single test; available through all Australian pathology providers (MBS item 69500 series). Use human recombinant tTG antigen. |
| Total serum IgA | Mandatory companion test with tTG-IgA | N/A (quantitative) | N/A | Selective IgA deficiency occurs in 1:300–1:700 coeliac patients (vs 1:600 general population). IgA <0.07 g/L = deficiency. |
| DGP IgG (deamidated gliadin peptide IgG) | Patients with selective IgA deficiency | 80–95% | 90–98% | Preferred second-line test when IgA is deficient. Superior to older gliadin antibody assays. |
| tTG-IgG | Alternative in IgA deficiency if DGP unavailable | 80–90% | 90–95% | Less sensitive than DGP IgG for IgA-deficient patients but acceptable alternative. |
| EMA IgA (endomysial antibody IgA) | Confirmatory test (second-line); near 100% specificity | 85–95% | 99–100% | Immunofluorescence-based; operator-dependent. Used to strengthen diagnostic certainty when tTG-IgA is weakly positive. |
Interpretive Algorithm
1
Order tTG-IgA + total IgA simultaneously
Ensure patient is consuming gluten (≥2 g/day for ≥6 weeks). MBS-rebated in Australia.
2
If IgA sufficient AND tTG-IgA positive
Refer to gastroenterology for confirmatory duodenal biopsy. Continue gluten in diet.
3
If IgA deficient (<0.07 g/L)
Order DGP IgG or tTG-IgG. tTG-IgA is unreliable. Positive result → GI referral for biopsy.
4
If serology negative but clinical suspicion remains high
Consider EMA IgA, repeat testing in 3–6 months, or proceed to biopsy. Do not exclude coeliac disease on a single negative serology if symptoms are compelling.
Infants under 2 years: tTG-IgA may be falsely negative in very young children (<2 years) with early-stage disease. In this age group, DGP IgG has higher sensitivity. If clinical suspicion is strong, consider combining DGP IgG with tTG-IgA.
Paediatric Considerations — Potential Biopsy-Free Diagnosis
The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2020 criteria, which are increasingly adopted in Australian paediatric practice, allow a biopsy-free diagnosis in symptomatic children when ALL of the following are met: (1) tTG-IgA ≥10× upper limit of normal, (2) EMA IgA positive on a separate sample, (3) HLA-DQ2 or DQ8 positive, and (4) symptoms resolve on GFD. Confirmation by a paediatric gastroenterologist is still recommended.
Confirmatory Biopsy & Referral
In Australia, upper gastrointestinal endoscopy (gastroscopy) with duodenal biopsy remains the gold standard for confirming coeliac disease in adults and most children. This should be performed by a gastroenterologist or specialist endoscopist.
Endoscopic Biopsy Protocol
- Minimum biopsies: ≥4 duodenal biopsies total — at least 2 from the distal descending (2nd part) duodenum and at least 2 from the duodenal bulb. This is because villous atrophy may be patchy, and bulbar disease can be the sole site of involvement.
- Orientation and processing: Specimens should be oriented on filter paper and sent in formalin for haematoxylin–eosin staining; CD3 immunohistochemistry for intraepithelial lymphocyte (IEL) quantification is recommended.
- Ongoing gluten intake: The patient must continue consuming gluten until the biopsy is obtained. A minimum of 2 g gluten/day (approximately 4 slices of bread) for ≥6 weeks prior to endoscopy is recommended. Initiating GFD before biopsy is the most common cause of diagnostic uncertainty.
Marsh Classification of Duodenal Histology
| Marsh Grade | IELs (per 100 enterocytes) | Crypt Hyperplasia | Villous Architecture | Interpretation |
|---|---|---|---|---|
| Marsh 0 | <25 | Normal | Normal | Normal mucosa |
| Marsh 1 | ≥25 (increased IELs) | Normal | Normal | Infiltrative — non-specific; may be seen in H. pylori, NSAIDs, other causes |
| Marsh 2 | ≥25 | Increased | Normal | Infiltrative–hyperplastic — consistent with coeliac disease when combined with positive serology |
| Marsh 3a | ≥25 | Increased | Mild partial villous atrophy | Diagnostic of coeliac disease (with positive serology) |
| Marsh 3b | ≥25 | Increased | Subtotal villous atrophy | Diagnostic of coeliac disease |
| Marsh 3c | ≥25 | Increased | Total villous atrophy | Diagnostic of coeliac disease — severe |
Diagnostic confirmation requires: Marsh ≥2 lesion on duodenal biopsy + positive coeliac serology (tTG-IgA, EMA, or DGP in IgA deficiency). Clinical improvement on GFD supports the diagnosis. HLA-DQ2/DQ8 testing has a high negative predictive value (~99%) and can be used to exclude coeliac disease when histology and serology are discordant.
Referral Pathway in Australia
- Urgent GI referral if serology strongly positive (tTG-IgA >10× ULN) with classic symptoms — particularly in children per ESPGHAN criteria.
- Routine GI referral for confirmatory biopsy in all patients with positive serology. Public hospital gastroenterology waiting times vary (4–12 weeks in metropolitan areas, longer in regional/rural). Private referral may be faster.
- Telehealth GI consultation is increasingly available (MBS telehealth items) for regional and remote patients, though endoscopy still requires procedural access.
- HLA-DQ2/DQ8 typing (MBS-rebated) is useful when there is diagnostic uncertainty: a negative result effectively excludes coeliac disease. Available through major Australian pathology providers.
When Biopsy May Not Be Required
In selected paediatric patients meeting ESPGHAN 2020 non-biopsy criteria (as above) and in some adult clinical scenarios, a biopsy-free pathway may be considered in consultation with a gastroenterologist. However, in Australian practice, biopsy confirmation remains the standard approach for adults and is recommended by GESA.
Differential Diagnosis to Consider
- Small intestinal bacterial overgrowth (SIBO)
- Giardiasis
- Autoimmune enteropathy
- Crohn's disease (duodenal involvement)
- Tropical sprue
- Eosinophilic gastroenteritis
- Drug-induced villous atrophy (olmesartan, mycophenolate, NSAIDs, checkpoint inhibitors)
- Common variable immunodeficiency (CVID)
Long-Term Management
The cornerstone of coeliac disease management is strict lifelong adherence to a gluten-free diet (GFD). There are currently no approved pharmacological therapies for coeliac disease in Australia, although clinical trials of gluten-degrading enzymes, tight-junction modulators, and immunotherapy approaches are underway.
Gluten-Free Diet — Core Principles
- Eliminate: Wheat, barley, rye, and their derivatives (including spelt, kamut, triticale). Standard oats are also excluded in Australia due to significant cross-contamination risk, although pure uncontaminated oats (<20 ppm gluten) remain debated — GESA recommends individual assessment and discussion with a dietitian.
- Safe grains/starches: Rice, corn (maize), potato, quinoa, buckwheat, millet, sorghum, amaranth, tapioca, certified gluten-free oats (where tolerated).
- Labelling: The Australia New Zealand Food Standards Code (Standard 1.2.3) requires mandatory declaration of gluten-containing cereals. "Gluten-free" labelling requires <20 ppm gluten (AOAC or Codex method). The Coeliac Australia endorsement logo (crossed grain) provides additional consumer assurance.
- Hidden gluten sources: Soy sauce (use tamari), beer/lager (use gluten-free beer), stock cubes, processed meats, some medications (starch excipients — generally wheat starch is now highly processed and considered safe in some European countries, but Australian guidelines recommend caution), communion wafers.
Dietitian referral is essential: All newly diagnosed patients should be referred to an Accredited Practising Dietitian (APD) with expertise in coeliac disease. This is Medicare-rebated under a GP Management Plan (GPMP) and Team Care Arrangement (TCA) — up to 5 allied health visits per calendar year (MBS items 10950–10970). Coeliac Australia also provides state-based dietitian services, support groups, and resources.
Monitoring Framework
| Parameter | Frequency | Details |
|---|---|---|
| Symptom review | 3–6 months post-diagnosis, then annually | Gastrointestinal symptoms, energy levels, weight |
| tTG-IgA titre | 6 months post-GFD, then annually until normalised | Declining titres confirm GFD adherence; normalisation expected in 6–12 months. Persistent elevation → assess adherence or consider refractory disease. |
| Iron studies | At diagnosis, 6 months, then annually | Ferritin, transferrin saturation. Iron deficiency may persist for months despite GFD. |
| Folate, vitamin B12 | At diagnosis, then annually | Deficiency common at diagnosis, particularly proximal small bowel involvement. |
| Vitamin D, calcium | At diagnosis, then annually | Vitamin D deficiency is prevalent in Australian coeliac patients; supplementation often required. |
| Zinc | At diagnosis, then as needed | Zinc malabsorption may contribute to dermatological symptoms and impaired wound healing. |
| Thyroid function (TSH) | At diagnosis, then every 2–3 years | Autoimmune thyroiditis co-occurs in 10–30% of coeliac patients. |
| Bone mineral density (DEXA) | At diagnosis (adults); repeat at 2 years if abnormal; ongoing per risk | Osteoporosis/osteopenia present in up to 40–50% at diagnosis. Improvement expected with GFD but may be incomplete. |
| Liver function tests | At diagnosis, then as indicated | Elevated transaminases normalise in most patients with GFD adherence. |
Nutritional Supplementation
Many patients require temporary or ongoing supplementation due to malabsorption at diagnosis or ongoing micronutrient gaps:
Ferrous Sulphate
Ferro-Gradumet® · Generic · Iron replacement
Adult dose
325 mg PO daily–BD (contains 105 mg elemental Fe²⁺ per tablet)
Paediatric dose
3–6 mg/kg/day elemental iron PO, divided BID–TID
Route
Oral
Duration
Until ferritin >30 µg/L and Hb normalised (typically 3–6 months); continue until GFD restores absorption
Renal adjustment
No adjustment required
PBS status
✔ PBS General Benefit
Cholecalciferol (Vitamin D₃)
Ostelin® · Generic · Vitamin D replacement
Adult dose
Loading: 3,000–5,000 IU PO daily for 6–8 weeks if severely deficient (<25 nmol/L); Maintenance: 1,000–2,000 IU PO daily
Paediatric dose
400–1,000 IU PO daily (age-dependent; higher doses if deficient under specialist guidance)
Route
Oral
Duration
Ongoing, especially in patients with osteoporosis or persistent malabsorption
Renal adjustment
No adjustment; caution in CKD (prefer calcitriol under nephrology guidance)
PBS status
✔ PBS General Benefit (S8500 for calcitriol); OTC for cholecalciferol
Calcium Carbonate
Caltrate® · Generic · Calcium supplementation
Adult dose
500–600 mg elemental calcium PO BD (with food for best absorption)
Paediatric dose
Dietary target: 500–1,300 mg/day (age-dependent); supplement only if dietary intake insufficient
Route
Oral
Duration
Ongoing if osteoporosis or inadequate dietary calcium
Renal adjustment
Avoid in hypercalcaemia; monitor in CKD
PBS status
⚠ Not PBS-listed (OTC); dietary preferred
GFD Non-Response and Refractory Coeliac Disease
Re-evaluate if symptoms persist at 6–12 months on GFD: Up to 30% of patients have persistent symptoms. Causes include ongoing gluten exposure (most common — dietary review by APD), coexisting IBS/SIBO, microscopic colitis, pancreatic insufficiency, lactose intolerance, or — rarely — refractory coeliac disease (RCD). RCD (Type I and II) requires specialist management and carries an increased risk of enteropathy-associated T-cell lymphoma (EATL). Refer to gastroenterology for repeat biopsy, HLA typing, T-cell clonality (TCR gene rearrangement), and CT/PET imaging.
Investigations
Available Investigations in Australia
Essential
tTG-IgA (tissue transglutaminase IgA antibody)
First-line serology. MBS-rebated (item 69500 series). Available through all Australian pathology providers (Sonic, Healius, ACL, regional labs).
Essential
Total serum IgA
Must be ordered with tTG-IgA to detect selective IgA deficiency. MBS-rebated.
Available
Deamidated gliadin peptide (DGP) IgG
For IgA-deficient patients. Available through major Australian labs. MBS-rebated.
Available
Endomysial antibody (EMA) IgA
Immunofluorescence assay — near 100% specificity. Available at major centres. MBS-rebated.
Available
HLA-DQ2 / DQ8 genotyping
High negative predictive value (~99%). Useful for diagnostic exclusion. MBS-rebated through major genetic pathology providers.
Essential
Upper GI endoscopy with duodenal biopsies
Gold standard confirmation. ≥4 biopsies required. MBS items 30473/30475. Available at public and private endoscopy units; metropolitan and regional centres.
Available
Iron studies, folate, B12, vitamin D, calcium, zinc, LFTs, TFTs
Baseline and monitoring nutritional and autoimmune markers. All MBS-rebated. Available through all Australian pathology providers.
Available
DEXA (bone mineral density)
Baseline assessment for osteoporosis. MBS-rebated (item 12315) when indicated by clinical criteria. Available at most radiology practices.
Referral
CT abdomen / PET-CT
For suspected refractory coeliac disease or EATL evaluation. Specialist referral required.
Specialist
T-cell receptor (TCR) gene rearrangement / flow cytometry on biopsy
Distinguishes RCD Type I (polyclonal) from Type II (monoclonal — higher EATL risk). Performed at specialist centres with GI pathology expertise.
Special Populations
Paediatrics
Peak onset 6 months–2 years following gluten introduction; also common in school-age children with subtle presentations (behavioural change, growth faltering, dental enamel defects).
Consider non-biopsy diagnosis per ESPGHAN 2020 criteria in symptomatic children: tTG-IgA ≥10× ULN + positive EMA + HLA-DQ2/8 + symptom resolution on GFD.
Paediatric gastroenterology referral recommended for all newly diagnosed children.
School meal planning: Engage school canteens; Coeliac Australia provides "Gluten Free at School" resources.
Growth monitoring (height, weight, BMI percentile) at every visit. Repeat serology 3–6 months post-GFD.
Pregnancy
Undiagnosed or poorly controlled coeliac disease is associated with increased risk of miscarriage, intrauterine growth restriction (IUGR), preterm birth, and low birth weight.
Women with established coeliac disease on strict GFD have pregnancy outcomes comparable to the general population.
Ensure optimal folate supplementation: 500 µg/day (standard) or 5 mg/day (if high-risk or prior neural tube defect) — standard Australian antenatal recommendation.
Iron supplementation: Often required; use ferrous sulphate 325 mg PO daily. Monitor ferritin each trimester.
Coeliac serology can be unreliable in pregnancy (immunomodulation); defer new diagnostic testing to post-partum if non-urgent.
Elderly
Late-onset diagnosis is common; elderly patients may present primarily with osteoporotic fractures, anaemia, or cognitive decline rather than classical GI symptoms.
Higher risk of nutritional deficiency (calcium, vitamin D, B12, folate, iron, zinc); monitor more frequently.
GFD adherence can be challenging — support with dietitian visits, simplified meal plans, and carer education if in residential aged care.
Review medications for gluten-containing excipients. Coordinate with GP, geriatrician, and dietitian.
Renal Impairment
Patients with CKD on GFD have increased risk of hyperkalaemia (rice-based diets may be potassium-rich) — monitor potassium levels.
Calcium and vitamin D management requires coordination with nephrology; use calcitriol (active vitamin D) in advanced CKD rather than cholecalciferol.
Iron infusion (ferric carboxymaltose, iron polymaltose) may be preferred over oral iron in CKD with malabsorption — available at hospital day units (MBS-rebated for Authority Required indication).
Coeliac disease-associated IgA nephropathy is a recognized association; monitor urinalysis.
Hepatic Impairment
Coeliac disease is associated with autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis — screen with LFTs and autoantibodies if indicated.
Unexplained transaminase elevation normalises on GFD in most patients; if persistent, investigate for concurrent liver disease.
No specific hepatic dose adjustments for standard GFD-related supplements.
Coordinate hepatology and gastroenterology follow-up when co-existing liver disease is identified.
Immunocompromised
Patients on immunosuppressants (e.g., for associated autoimmune conditions) — serology may be less reliable; biopsy confirmation becomes more important.
Ensure vaccinations are up to date (influenza, pneumococcal, COVID-19) as per Australian Immunisation Handbook, particularly if on immunosuppressive therapy for co-morbid autoimmune disease.
Coeliac disease itself does not cause immunosuppression, but the associated conditions and their treatments may.
Coordinate with rheumatology/endocrinology for patients with overlapping autoimmune conditions.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
The prevalence of coeliac disease in Aboriginal and Torres Strait Islander Australians is not well characterised, but available evidence suggests it is under-diagnosed. HLA-DQ2 haplotype frequency in Indigenous Australians is lower than in European-descent populations, suggesting potentially lower genetic susceptibility; however, coeliac disease does occur and may present atypically or be masked by other causes of malabsorption, chronic diarrhoea, and nutritional deficiency that are more prevalent in remote communities.
Key clinical point: Iron-deficiency anaemia and chronic diarrhoea are common in remote Aboriginal and Torres Strait Islander communities due to multiple causes (hookworm, chronic infections, nutritional deficiency). Coeliac disease should be considered in the differential diagnosis, particularly when these features are unexplained or fail to respond to standard management.
Quick Reference — Coeliac Disease Diagnostic & Monitoring Summary
Screening (first-line)
tTG-IgA + total IgA
While on gluten (≥2 g/day × 6 weeks)
If IgA deficient → DGP IgG
Confirmation
Upper GI endoscopy + ≥4 duodenal biopsies
Marsh ≥2 + positive serology
Gastroenterology referral
Treatment
Strict lifelong GFD
Ongoing
Dietitian referral essential
Monitoring (serology)
tTG-IgA
6 months, then annually
Declining titres = good adherence
Monitoring (nutrition)
Iron, folate, B12, vit D, calcium, zinc
Baseline → 6 months → annually
Supplement as needed
Bone health
DEXA scan
At diagnosis (adults); repeat at 2 years if abnormal
Treat osteoporosis per guidelines
Refractory disease
Re-biopsy + HLA + TCR clonality
If symptoms persist ≥12 months on strict GFD
Exclude EATL; specialist management
📚 References
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