Recognition and assessment of coeliac disease

1. Recognition and assessment of coeliac disease Implementing NICE guidance 2009 NICE clinical guideline 86

2. What this presentation covers Background Scope Recommendations Costs and savings Discussion Find out more

3. Background • Coeliac disease is a state of heightened immune response to ingested gluten in genetically susceptible people • It is believed to be present in up to 1 in 100 of the population • It often goes unrecognised and is consequentlyunder-diagnosed. Only 10–15% of people with the condition are thought to be clinically diagnosed and some people have no symptoms • There is some uncertainty about which serological tests are most suitable for use in the diagnostic process

4. Scope • The guideline covers recognition, assessment and investigation of people who present with gastrointestinal or non-gastrointestinal symptoms or signs that are suggestive of coeliac disease • The target population is adults and children with symptoms and/or signs that suggest coeliac disease

5. Recommendations The key areas for recommendations are: • When to offer testing • Dietary considerations before testing • Other information before serological testing • Serological tests • After serological tests

6. When to offer testing • Offer serological testing to people with any of the symptoms, signs and conditions associated with coeliac disease • Consider offering serological testing to people with conditions that are sometimes associated withcoeliac disease

7. Dietary considerations before testing Inform people that: • testing is accurate only if they follow a gluten-containing diet • when following a gluten-containing diet they should eat some gluten in more than one meal every day for at least 6 weeks before testing • they should not start a gluten-free diet until diagnosis is confirmed by intestinal biopsy

8. Other information before serological testing • Inform people that any result from self-testing needs to be discussed with a healthcare professional and confirmed by laboratory results • Explain what coeliac disease is, the purpose of serological tests and what the results mean, and the implications of a positive or negative test • Inform people that a delayed diagnosis can result in continuing ill health and long-term complications, and in children can result in growth problems

9. Serological tests: 1 • Tests should be undertaken in laboratories with clinical pathology accreditation • Do not use immunoglobulin G (IgG) and immunoglobulin A (IgA) anti-gliadin antibody (AGA) tests • Do not use self-tests and/or point-of-care tests for coeliac disease as a substitute for laboratory-based testing • Do not use human leukocyte antigen (HLA) DQ2/DQ8 testing in the initial diagnosis of coeliac disease

10. Serological tests: 2 Laboratories should use tests in the following order: • IgA tissue transglutaminase (tTGA) as the first choice • If tTGA test is equivocal, use IgA endomysial antibodies (EMA) test • If serology is negative, check for IgA deficiency • If IgA deficiency is confirmed, use IgG tTGA and/or IgG EMA serological tests Values and interpretation of results, and recommended actions should be communicated clearly

11. After serological tests Offer referral to a gastrointestinal specialist for intestinal biopsy, to confirm or exclude coeliac disease, to people with: • positive serological results • negative serological results but with continuing clinical suspicion

12. Costs per 100,000 population

13. Discussion • How do we improve recognition of coeliac disease in people presenting with the signs, symptoms and conditions associated with coeliac disease? • What serological tests and testing strategies do we use in the diagnostic process for coeliac disease and are these the ones recommended in this guideline? • How do we ensure that patients are given all the necessary information on: • dietary considerations before testing for coeliac disease • the diagnostic process?

14. Find out more Visit www.nice.org.uk/CG86 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • audit support • commissioning factsheet • guide to resources