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