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CPD ACTIVITY 71 with the consequences of malabsorption such as deficiency states (eg, iron deficiency), fatigue, headaches, elevated transaminases, osteoporosis, infertility or dermatitis herpetiformis. Iron deficiency anaemia is the most common clinical presentation in adults.2 Up to 75 per cent of people with coeliac disease are undiagnosed.1 Dermatitis herpetiformis is the skin manifestation of active coeliac disease. It appears as multiple intensely pruritic papules and vesicles that occur in grouped arrangements. The elbows, forearms, knees, scalp, back and buttocks are the most common sites affected. Dermatitis herpetiformis responds to gluten withdrawal but this may be gradual and episodes can recur even on a strict gluten-free diet.5 (Refer to the Figure on page 72). If a person has any of the symptoms listed above they should be advised to see their GP for a thorough examination and consideration for testing. If a diagnosis is confirmed, immediate family members should be screened for the disease.6 Testing A gluten free diet should not be started until the condition has been properly diagnosed. If gluten has been removed from the diet, a normal diet must be resumed at least six weeks prior to testing.7 Serological testing for coeliac disease consists of tTG-IgA and deamidated gliadin peptide (DGP)-IgG antibody tests. Gastroscopy with biopsy of small intestine is required to confirm a diagnosis of coeliac disease after a positive tTG-IgA and/or DGP-IgG test.6 If a positive diagnosis is confirmed with testing, screening for complications and associated conditions should occur.6 What are the long-term risks of coeliac disease? It’s important to establish a diagnosis of coeliac diseases so that the small bowel can heal and the long-term consequences can be prevented or reversed where possible with the introduction of a gluten free diet. Although symptoms can vary, everyone with coeliac disease is at risk of complications if they don’t adhere strictly to a gluten free diet. Damage to the small bowel can still occur if gluten is ingested in people who are asymptomatic. As little as 50mg of gluten (equivalent to 1/100th of a slice of standard wheat bread) can damage the small intestine in people with coeliac disease.7 Untreated coeliac Table 1. Complications of coeliac disease Complication Description Malignancy Studies have noted a small increase in overall mortality in patients with coeliac disease. The association is strongest for lymphoma and gastrointestinal cancer. The magnitude of increased risk is moderate (standardised incidence ratio of 1.3) and appears to normalise within a few years of gluten withdrawal.5 Neuropsychiatric disease Coeliac disease is associated with headache, neurobehavioral disorders, anxiety and depression, and peripheral neuropathy.5 Osteoporosis Reduced bone mineral density (BMD) related to secondary hyperparathyroidism due to vitamin D deficiency is common in coeliac disease. BMD may normalise on a long-term gluten free diet, although this is less likely in older adults with a late diagnosis.5 Iron deficiency anaemia Coeliac disease is a frequent cause of iron deficiency anaemia. Folate (and rarely vitamin B12) deficiency may lead to macrocytic anaemia. Infertility Recurrent spontaneous abortion and infertility can be manifestations of coeliac disease.5 Other autoimmune conditions Autoimmune thyroid disease (Graves’ disease or Hashimoto’s disease) and autoimmune diabetes (type 1 diabetes or latent autoimmune diabetes) have an increased incidence among patients with coeliac disease.5 disease increases the risk of complications listed in Table 1. Non-coeliac gluten sensitivity Many people experience gastrointestinal problems such as diarrhoea, bloating, abdominal pain and nausea. They may also notice that these symptoms improve if they remove or decrease gluten in their diet. However, this doesn’t necessarily mean they have coeliac disease. It’s important that they see their doctor to determine the cause of any symptoms. A small number of people may be suffering from a non-coeliac gluten sensitivity, which is a syndrome of intolerance to gluten ingestion in patients with no serological or histological evidence of coeliac disease. In some people these symptoms occur, not as a result of exposure to gluten, but as a result of exposure to fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs).6 Wheat, barley and rye-based bread, along with other foods such as garlic, onions, apples, milk and yoghurt, are high in FODMAPs. As these sugars are also reduced in a gluten free diet, a favourable clinical response may result but is likely due to a reduction in oligosaccharides rather than from the elimination of gluten. These people may have irritable bowel syndrome. Unlike a gluten free diet, a low FODMAP diet is not a lifetime diet. It’s usually recommended for two to six weeks at a time, until the symptoms have improved. Once certain foods have been reintroduced again, some people find they only need to avoid some of the high FODMAP foods.8 Pharmacists should recommend that people with symptoms of intolerance to foods containing gluten see their doctor. It is important that a definitive diagnosis is made so that, if a person is found to have coeliac disease, a strict gluten free diet can be instituted, screening for complications can occur and further damage be prevented. People who self-diagnose gluten sensitivity because a gluten free diet makes them feel better may be unnecessarily restricting their diet, with the potential for developing other deficiencies. Management of coeliac disease Currently, the only treatment for coeliac disease is adoption of a strict, lifelong gluten free diet. All food containing wheat, rye, barley and oats (and their derivatives) must be avoided.1,2,4 The exact gluten composition of oats is hotly debated. Oats cannot be advertised as gluten free in Australia due to our current food standards. But they’re considered to be gluten free in many other countries. People with coeliac disease will notice an improvement of their symptoms once they adopt a gluten free diet. This can happen very quickly. Often within one week. However, resolution of small bowel damage takes several months after adoption of the diet. A follow-up endoscopy will confirm that the gluten free diet is aiding the bowel to heal and give insight to the specialist about how the patient may be managing their dietary restriction. People with coeliac disease usually become experts at managing their diet. However, adherence to a gluten free diet can be a challenge for some. Particularly for children who are diagnosed at an early age, when limiting treats such as cakes and fast food can be a challenge. Parents, family members, friends and carers of TO PAGE 72 RETAIL PHARMACY • JUL 2020