WALSALL COELIAC DISEASE FLOWCHART CLINICAL SUSPICION OF COELIAC DISEASE ( Which can present at any age ) [see Box A or Box B] DO NOT START GLUTEN FREE DIET BEFORE ANY INVESTIGATIONS Test for IgA Tissue transglutaminase antibodies & Immunoglobulins to exclude IgA deficiency ( Hospital serology only ). If ttga positive, (< 35 & EMA negative ignore) refer to gastroenterology specialist for consideration for gastroscopy and duodenal biopsies, for definite diagnosis. If Antibodies negative result, but continuing clinical suspicion due to symptoms, refer to gastroenterology specialist for opinion. All tests negative & coeliac disease excluded Positive result & diagnosis confirmed by gastroenterologist. Advise patient of result & to commence gluten free diet (explain use of long term FP10 scripts for GF foods). Inform GP of diagnosis & ask GP to supply FP10 scripts for gluten free products. Click here for appropriate quantities. Arrange appointment in nutrition clinic & refer to nurse led coeliac clinic for long term follow up, dietician & support group ( Coeliac UK ) for education. Further blood tests for: iron, Vitamin B12 & folate deficiency. Thyroid function tests, glucose, Calcium Profile and Vitamin D. Advise: adequate vitamin D & calcium supplements if at risk of osteoporosis. Bone density dexa scan in high risk patients. Suggest serological screening for first degree relatives. JN JAN 14 1
BOX A. Offer serological testing to children and adults with any of the following signs, symptoms & conditions: Signs & symptoms Conditions Chronic or intermittent diarrhoea Autoimmune thyroid disease Failure to thrive or faltering growth Dermatitis herpetiformis (in children). Irritable bowel syndrome Persistent or unexplained gastrointestinal Type 1 diabetes symptoms including nausea & vomiting First degree relatives (parents, Prolonged fatigue ( tired all the time ) siblings or children with coeliac disease Recurrent abdominal pain, cramping or distension. Unexplained iron deficiency anaemia or other unspecified anaemia Unexplained weight loss BOX B. Symptoms and conditions for which serological testing should be considered: Addison s disease Amenorrhoea Aphthous stomatitis (mouth ulcers) Autoimmune liver conditions Autoimmune thyroiditis Chronic thrombocytopenia purpura Dental enamel defects Depression or bipolar disorder Epilepsy Low trauma fracture Lymphoma Metabolic bone disease (osteomalacia) Microscopic colitis Persistent or unexplained constipation Persistently raised liver enzymes with unknown cause Polyneuropathy / unexplained ataxia Recurrent miscarriage Reduced bone mineral density Sarcoidosis Sjogren s syndrome Turner syndrome Unexplained alopecia Unexplained subfertility CLINICAL RESPONSIBILITY: Initial serology testing for coeliac disease can be done by the primary or secondary care clinician. Followed by diagnosis, further investigations and management plan being the responsibility of secondary care. Subsequent care including FP10 prescriptions for gluten free products and osteoporosis prevention being the responsibility of primary care. JN JAN 14 2
AIM OF PRESCRIBING GLUTEN FREE PRODUCTS Gluten free products are an essential part of the clinical treatment of coeliac disease and help patients with gluten sensitive enteropathies, including steatorrhoea due to gluten sensitivity and dermatitis herpetiformis ( DH) to follow a healthy, well balanced, lifelong gluten free diet to optimise nutrient absorption and nutritional status, as well as reduce the risk of long term complications including lymphoma and osteoporosis. All patients newly diagnosed with coeliac disease and those meeting the criteria for gluten enteropathy or DH should be offered a consultation with a dietician for further advice and education regarding a gluten free diet. The specialist nurse or dietician can recommend if needed, the specific requirements to the GP of gluten free products. It is not recommended that practices limit themselves to a narrow formulary, as nutritional content and therapeutic needs as well as personal beliefs of patients can vary ( i.e vegetarians ). Variety and acceptability of the diet can enhance adherence, with improvements in outcomes. The following tables aim to provide clarity on the recommended ranges, food types, quantities and units to prescribe in accordance with national recommendations: Table 1: Recommended amounts per month AGE & SEX UNITS PER MONTH Child 1-3 years 10 Child 4-6 years 11 { Prescribing below Child 7-10 years 13 recommended norms: Child 11-14 years 15 some patients may not require Child 15-18 years 18 their full amount each month. Dependent on choice,preference Male 19-59 years 18 & dietary intake.} Male 60-74 years 16 Male 75+ years 14 { Exceeding norms: Units may be exceeded in Female 19-74 years 14 certain situations as stated.} Female 75+ years 12 Breastfeeding Add 4 units Third trimester pregnancy Add 1 unit High physical activity level Add 4 units JN JAN 14 3
Table 2: Number of units for different foods: FOOD ITEM NUMBER OF UNITS 400G BREAD/ROLLS/BAGUETTES 1 500G FLOUR MIX 2 200G BISCUITS /CRACKERS 1 500G OATS 1.5 300G BREAKFAST CEREALS 1.5 250G PASTA 1 2 X 110G 180G PIZZA BASES 1 Table 3: Categories of ACBS approved gluten free products * This advice does not affect the clinical freedom of the prescriber Gluten free non fibre cereals are widely available Recommendation level * Type of product When to prescribe Staple In exceptional corcumstances Not recommended All types of bread, rolls or baguettes: all flour-type mixes; ( except cake mix) fibre containing breakfast cereals; pasta; crackers; crispbreads; pizza bases Biscuits; non fibre containing breakfast cereals, oat containing breakfast cereals ( assess potential for sensitivity to oats, may be helpful to exclude oats in the first 6-12 months of a gluten free diet.) Cake mixes & luxury items, such as cakes & chocolate biscuits, will not be prescribed. All patients with a diagnosis of gluten sensitive enteropathies, including steatorrhoea due to gluten sensitivity,coeliac disease and dermatitis herpetiformis ( DH ). Upon advice of dietician Patient is nutritionally at risk or compromised When specific snacks are required to manage childhood diabetes to optimise carbohydrate distribution Prescribing not recommended References: Clinical Resource Efficiency Support Team ~ Diagnostic Algorithm for serological Testing in Coeliac Disease ( 2006 ). World Gastroenterology Organisation Practice Guidelines ~ Screening for coeliac disease ( 2007 ) National Institute for Health and Clinical Excellence ~ Coeliac Disease: recognition & assessment of coeliac disease. Clinical guideline 86 NICE, London ( 2009 ). All Wales Guide to prescribing Gluten free products ~ All Wales medicines Strategy Group ( 2013 ) Coeliac UK Gluten free foods : a revised prescribing guide ( 2011 ) ; Prescribable products List ( 2013). Coeliac.org.uk accessed - December 2013 JN JAN 14 4
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