Nursing in Practice March/April 2019 (issue 107) - Page 15

Supported by an educational grant by Thermo Fisher The National Institute for Health and Care Excellence (NICE) recommends patients are tested for coeliac disease when they are diagnosed with type 1 diabetes. However, tests may initially return negative results 8 and need to be repeated later. During reviews, follow-ups and other consultations with patients with type 1 diabetes, use the opportunity to ask whether the patient has any new or unexplained symptoms that could indicate coeliac disease and refer for testing if necessary. Consider referring patients with both type 1 diabetes and coeliac disease to a dietitian for specialist advice about adhering to a gluten-free diabetic diet. Osteoporosis – think coeliac Reduced bone mineral density is reportedly evident in up to three-quarters of coeliac patients on diagnosis. 9 The risk of osteoporosis in people with coeliac disease is higher when diagnosis is delayed, due to ongoing malabsorption of calcium. Also, the inability to absorb dietary nutrients can cause weight loss and low body mass index – another risk factor for osteoporosis. The risk is also increased in people who are lactose intolerant as a result of undiagnosed coeliac disease, because Testing for coeliac disease The first step in diagnosing or ruling out coeliac disease is serological testing. NICE guidelines state that this should be offered to patients with any of the following: • persistent unexplained abdominal or gastrointestinal symptoms • delayed growth • prolonged fatigue • unexplained weight loss • unexplained iron, vitamin B12 or folate deficiency • type 1 diabetes (at diagnosis) • autoimmune thyroid disease (at diagnosis) • irritable bowel syndrome (in adults) • first-degree relatives with coeliac disease. The guidelines also suggest that testing should be considered in patients with: • metabolic bone disorder (reduced bone mineral density or osteomalacia) consuming gluten over time damages the part of the gut that produces lactase, which breaks down lactose. Consider the possibility of coeliac disease in patients with reduced bone mineral density, particularly those who are middle-aged. Be mindful that 3.5 million people over the age of 50 in the UK live with osteoporosis, 10 and coeliac disease is most commonly diagnosed between the ages of 40 and 60. 11 Refer for testing if necessary. Subfertility – think coeliac Evidence suggests that women with coeliac disease who follow a gluten-free diet are at no significantly greater risk of subfertility than non-coeliac women. A 2014 study showed that rates of infertility were 41% higher in women aged 25 to 29 with coeliac disease compared with the general population of women of the same age. 12 However, untreated coeliac disease is a potential underlying cause of some fertility problems – but it is not known exactly why. 13 When consulting with women who present with subfertility and/or recurrent miscarriage, ask about other symptoms that could indicate coeliac disease. Consider referring for testing as appropriate. • unexplained neurological symptoms (particularly peripheral neuropathy or ataxia) • unexplained subfertility or recurrent miscarriage • persistently raised liver enzymes with unknown cause • dental enamel defects • Down’s syndrome • Turner syndrome. If you suspect coeliac disease, refer the patient to their GP for testing or seek further advice. Serological testing in people with suspected coeliac disease should be carried out as early as possible. It will enable those who test positive to undergo additional tests to confirm the diagnosis, avoid further suffering and unnecessary mucosal damage to the gut lining, and start managing their illness. Management of patients with coeliac disease Treatment for coeliac disease is a lifelong gluten-free diet. Despite gluten-free foods being more widely available now than ever before (including on prescription in many parts of the UK), many people struggle to adhere. Signpost reliable sources of information and advice, like Coeliac UK’s resources on eating well on a gluten-free diet at www.coeliac.org. uk/gluten-free-diet-and-lifestyle/gf-diet. However, if a patient has not been diagnosed and is undergoing tests for coeliac disease, counsel them about the importance of not restricting gluten intake: people should continue to eat gluten in at least one meal a day for six weeks before testing to yield accurate results. Primary Care Society for Gastroenterology guidelines recommend that patients with diagnosed and well-managed coeliac disease should have long-term follow-up once a year in primary care. 14 However, if you encounter patients whose symptoms persist, and whose disease is poorly controlled, it’s important they see their GP in the first instance for further support, and onward referral to gastroenterology services if needed ● References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Hadjivassiliou M, Grünewald RA, Sharrack B, et al. Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics. Brain. 2003;126:685–91. http://www.coeliac.org.uk/coeliac-disease/about- coeliac-disease-and-dermatitis-herpetiformis/ symptoms www.coeliac.org.uk/about-us/news/coeliac-disease- diagnosis-rises-to-30-but-still-missing-half-a Gray AM, Papanicolas IN. Impact of symptoms on quality of life before and after diagnosis of coeliac disease: results from a UK population survey. BMC Health Serv Res. 2010;10,105. Norström F, Lindholm L, Sandström O et al. Delay to celiac disease diagnosis and its implications for health-related quality of life. BMC Gastroenterol. 2011;11,118. www.celiac.org/about-celiac-disease/related- conditions/autoimmune-disorders www.diabetes.org.uk/guide-to-diabetes/enjoy-food/ eating-with-diabetes/managing-other-medical- conditions/coeliac-disease-diabetes www.coeliac.org.uk/coeliac-disease/associated- conditions-and-complications/type-1-diabetes www.coeliac.org.uk/healthcare-professionals/ management/associated-conditions-and- complications/osteoporosis www.iofbonehealth.org/facts-statistics www.coeliac.org.uk/coeliac-disease/myths-about- coeliac-disease Dhalwani N, West J, Sultan A, et al. Women with celiac disease present with fertility problems no more often than women in the general population. Gastroenterology. 2014; 147:1267–1274. www.coeliac.org.uk/coeliac-disease/associated- conditions-and-complications/fertility-problems www.pcsg.org.uk/coeliac-guidelines