Long-term follow-up in adults with coeliac disease: Predictors and effect on health outcomes

Celiac Disease Affects 1% of Global Population: Who Will Manage All These Patients?

Celiac disease is a common gastrointestinal condition with an estimated global prevalence of up to 1%. Adequate long-term surveillance of patients is imperative to ensure strict adherence to treatment with a gluten-free diet and the ensuing clinical and histologic recovery. Traditionally, this has been accomplished by means of regular on-site attendance at specialist health care facilities, accompanied for most patients by follow-up endoscopic and laboratory tests. However, the rapidly increasing prevalence of celiac disease and the limited health care resources challenge the current centralized and nonindividualized follow-up strategies. The improved noninvasive surveillance tools and online health care services are further changing the landscape of celiac disease management. There is a clear need for more personalized and on-demand follow-up based on early treatment response and patient-related factors associated with long-term prognosis. Additional scientific evidence on the optimal implementation of follow-up for pediatric and adulthood celiac disease is nevertheless called for.

Adherence to a gluten-free diet in celiac disease patients from Paraguay

INTRODUCTION AND AIM

The treatment for celiac disease is a gluten-free diet that should be strictly and permanently carried out. Our aims were to determine adherence to the gluten-free diet and the risk factors for non-adherence.

MATERIALS AND METHODS

An observational, cross-sectional, comparative study was conducted. It included individuals of both sexes and of any age that presented with celiac disease, lived in Paraguay from January to April 2021, and agreed to participate in the survey. Incomplete questionnaires were excluded. Non-probabilistic convenience sampling was utilized. Adherence was measured using the Leffler questionnaire. The study was approved by the Ethics Committee of the Universidad Privada del Este.

RESULTS

The sample consisted of 371 respondents, 322 (87%) of whom were adults, with a mean age of 38 ± 12 years, and 49 (13%) of whom were children and adolescents, with a mean age of 10 ± 5 years. Female sex was predominant (85%). Adherence to the gluten-free diet was detected in 59% of the adults and 73% of the children and adolescents. The factors significantly associated with adherence included belonging to the child and adolescent age group and having had the diagnosis for a longer time: 9 ± 8 years for the adherence group and 7 ± 8 years for the non-adherence group.

CONCLUSIONS

The present study demonstrated the frequency of adherence to the gluten-free diet in celiac patients in Paraguay. Psychologic and nutritional support is recommended for individuals with celiac disease that do not adhere to their treatment.

Follow-Up of Celiac Disease in Adults: "When, What, Who, and Where"

For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice-it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0-1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD.

Coexisting Type 1 Diabetes, Persistent Symptoms, and Financial Issues Associate With Poorer Adherence to a Gluten-Free Diet in Celiac Disease After Transition From Pediatrics to Adult Care

Purpose

We evaluated adherence to a gluten-free diet and associated factors in adult celiac disease patients diagnosed in childhood.

Methods

Comprehensive medical data on 955 pediatric celiac disease patients was collected and study questionnaires sent to 559 who were now adults. All variables were compared between strictly adherent and non-adherent patients.

Results

Altogether 237 adults (median age 27 years, 69% women) responded to the questionnaires a median of 18 (range 3-51) years after the childhood diagnosis. Altogether 78% were reportedly adherent and 22% non-adherent. The non-adherent patients had more concomitant type 1 diabetes (18% vs. 4%, p = 0.003), whereas the groups did not differ in demographic data or clinical and histological features at diagnosis, or in short-term dietary adherence. In adulthood, non-adherent patients found gluten-free diet more challenging (39% vs. 17%, p < 0.001) and had higher prevalence (39% vs. 19%, p = 0.004) and severity of symptoms. The main motivation factors for dietary adherence were attempts to avoid symptoms and complications, but these were considered less important and price of gluten-free products more important among non-adherent patients. Adherent and non-adherent patients did not differ in socioeconomic or lifestyle factors, comorbidities other than type 1 diabetes, self-reported general health, health concerns, follow-up, or in quality of life.

Conclusion

Most originally pediatric celiac disease patients reported strict dietary adherence in adulthood. However, particularly those with concomitant type 1 diabetes, persistent symptoms or financial issues may require attention during the transition from pediatric to adult care.

Risk of Drop-Out from Follow-Up Evaluations for Celiac Disease: Is It Similar for All Patients?

Background: Celiac disease (CD) follow-up is a relatively underevaluated topic. However, correct adherence to follow-up procedures is central to the early recognition of complicated CD and other conditions typically associated with CD. Establishing whether patients at increased risk of complications follow clinicians’ recommendations has multiple repercussions. Methods: We retrospectively analyzed the records of patients consecutively diagnosed with CD in our outpatient clinic between January 2004 and October 2017 to investigate the factors associated with drop-out from follow-up procedures. Results: Among the 578 patients analyzed, 40 (6.9%) dropped out during the first six months and 272 (50.6%) during the observation period. The median time to drop-out was 7.4 years (95% confidence interval: 6.8−8.0). No factors were associated with early drop-out. Instead, age at diagnosis >40 years (40−59 years, p < 0.001; ≥60 years, p = 0.048) and classical clinical presentation (p = 0.016) were significantly associated with a lower risk of later drop-out. Conclusions: Patients at increased risk of complicated CD are more compliant with follow-up procedures than patients at lower risk, despite being prescribed the same controls. These results indirectly support the hypothesis of tailored follow-up strategies, differentiated according to the risk of complications.

Management of coeliac disease patients after the confirmation of diagnosis in Central Europe

BACKGROUND

Recently published paediatric guidelines for diagnosing coeliac disease do not include recommendations on the follow-up of coeliac disease patients.

GOAL

The aim of this study was to assess the management practices and experience of coeliac disease patients with their follow-up appointments in Central Europe.

STUDY

Gastroenterologists and coeliac disease patients in five Central European countries were asked to complete the web-based questionnaire focusing on coeliac disease management practices.

RESULTS

Answers from 147 gastroenterologists and 2041 coeliac disease patients were available for the analysis. More than half of the gastroenterologists (58.5%) schedule the first follow-up visit within 3 months after the diagnosis. At follow-up, tissue transglutaminase antibodies are checked in almost all patients (95.9%). Approximately two-thirds (60.7%) of gastroenterologists refer all of their patients to the dietitian at diagnosis. Similarly, 42.8% of coeliac disease patients reported that they had not been appointed to a dietitian. Almost one-third of coeliac disease patients (30.8%) reported that they had no follow-up appointments with gastroenterologist at all.

CONCLUSIONS

Follow-up of coeliac disease patients is suboptimal in Central Europe. Many patients are not followed regularly. A lot of patients are not referred to a dietitian. The recommendations on the optimal follow-up of coeliac disease patients are needed in order to improve patient care.

Adherence to gluten-free diet and follow-up of pediatric celiac disease patients, during childhood and after transition to adult care

Long-term data on pediatric celiac disease (CD) patients after transition to adult care is scarce. We aimed to evaluate patients' adherence to a gluten-free diet (GFD), the normalization of celiac serology and the frequency of follow-up before age 18, and to study changes in adherence and follow-up frequency after transition to adult care. Presenting symptoms, serology and biopsy results, patients' reported GFD adherence, frequency of follow-up visits, and complications before and after 18 years were collected for CD patients diagnosed between 1998 and 2017. Of 441 CD patients diagnosed and followed in childhood, a quarter (108/441) were over 18 y (years) at data collection. Median age at diagnosis 7.1 y (9 months-18 y), at data collection 23 y (18-38 y), disease duration 11.3 y (2-36 y). Below the age of 18 y, most patients 386/436 (88.5%) reported adherence to GFD, and most 372/425 (85.7%) normalized serology. Of the 441 patients, only 3 failed to attend any follow-up visit, and 338/441 (76.6%) attended yearly visits. Over the age 18 y, serology testing was done in 78/108 (72.2%), every 1-3 y in 46/78 (59%). Serology normalized in 61/78 (78.2%). Most adult patients 77/108 (71.5%) never attended a gastroenterology clinic. CD-related complications were rare. Younger age at diagnosis, regular follow-up visits in childhood, resolution of symptoms, and normalization of serology before age 18 were identified as predictors of negative serology after the age of 18 y.Conclusions: Children who have regular follow-up and normalize serology before age 18 years are likely to maintain a GFD and have negative serology as adults. What is Known: • The rate of adherence to gluten-free diet (GFD) is higher among children compared to adults. • Data on long-term follow-up after transition to adult care is scarce. What is New: • Patients diagnosed with CD at a younger age (<12 y), who have yearly follow-up visits, resolution of symptoms, and negative serology in childhood are very likely to maintain GFD and have negative serology as adults. • Even though most patients do not attend GI clinics after transition to adulthood, most adhere to GFD, and complications are rare.

Well-being and dietary adherence in patients with coeliac disease depending on follow-up

OBJECTIVE

It is not clear how follow-up of coeliac disease should be optimally organised. In Malmö, Sweden, patients are followed up by general practitioners (GP), but in Linköping by gastroenterologists (GE). The aim of this study was to investigate if there were any differences in well-being and dietary adherence depending on type of follow-up.

METHODS

All adult patients with newly diagnosed biopsy-verified coeliac disease in the cities between 2010 and 2014 were offered to participate. Data was retrieved comprising demography, laboratory analyses, questionnaires (Gastrointestinal Symptoms Rating Scale, Short Health Scale, Multidimensional Fatigue Inventory, Psychological General Well-being Index and Short Form 36) and follow-up.

RESULTS

In the GP cohort 39/73 patients and in the GE cohort 58/121 agreed to participate (mean age 43 and 44 years, 69 and 60% women, respectively). A follow-up to a dietician was carried out in 31% and 93% of patients, respectively (p < .001). In the GP group 28% had eaten gluten-containing food during the last 4 weeks compared to 9% in the GE group (p = .01). Despite this, no differences could be seen in vitamin or mineral levels. The questionnaires did not indicate any major discrepancies in subjective health.

CONCLUSION

Irrespective of the design of the follow-up physical and mental well-being were comparable. Dietary adherence was not quite as good in the GP group but follow-up in a primary care setting can still be a suitable and equivalent alternative. However, it is crucial that the dietary counselling is structured in a way that ensures dietary adherence.

Lack of long-term follow-up after paediatric-adult transition in coeliac disease is not associated with complications, ongoing symptoms or dietary adherence

BACKGROUND

Follow-up of coeliac disease is recommended to prevent complications associated with unsuccessful treatment.

OBJECTIVE

The objective of this article is to evaluate the implementation and significance of long-term follow-up.

METHODS

Medical data were collected from 585 and follow-up questionnaires sent to 559 current adult coeliac disease patients diagnosed in childhood. Diagnostic features and adulthood health outcomes were compared between those with and without adulthood follow-up.

RESULTS

Of paediatric patients, 92% were followed up 6-24 months after diagnosis. A total of 235 adults responded to the questionnaires a median of 18 years after diagnosis, and 25% of them reported regular follow-up. They were diagnosed more recently than those without follow-up (median year 2001 vs 1995, p = 0.001), being otherwise comparable at diagnosis. Those with follow-up were less often smokers (5% vs 16%, p = 0.042) and relatives of coeliac patients (48% vs 66%, p = 0.018), and more often students (48% vs 28%, p = 0.005) and type 1 diabetics (19% vs 4%, p = 0.001). Lack of follow-up was not associated with complications, ongoing symptoms, poorer general health or dietary adherence. All completely non-adherent patients were without follow-up.

CONCLUSIONS

Most coeliac disease patients diagnosed in childhood were not followed up according to recommendations in adulthood. The individual effect of this on long-term treatment outcomes varied markedly.