Patients should be referred to a dietician at diagnosis, and then have yearly check-ups to instruct and monitor their gluten-free diet adherence. Following the initiation of a gluten-free diet, there may be discordance between normalisation of immunoglobulin A-tissue transglutaminase (IgA-tTG) and mucosal healing. Complete mucosal recovery takes varying amounts of time; less than half of patients with coeliac disease show normalisation of duodenal histology after 1 year on a gluten-free diet, with adults being less likely than children to show mucosal healing. Symptoms are poor predictors of mucosal inflammation or recovery.
If the patient is in clinical and serological remission after 1 year on a gluten-free diet, annual follow-up interval for the following 2 years may be considered, and then every 2 years thereafter.
Patients should be prescribed oral supplementation to treat any nutritional deficiencies present at diagnosis, and should be monitored until deficiences are resolved.
IgA-tTG titres are typically checked at least three times in the first year following the diagnosis (3 months, 6 months, and 12 months), and then yearly as an indication of diet adherence. In most patients, IgA-tTG titre should normalise within 6 to 9 months, but it may take more than 3 years in some patients (e.g., children with severe mucosal atrophy, type 1 diabetes, and very high titres at the time of diagnosis). No immediate action is required if the IgA-tTG titre is trending down, the patient is asymptomatic, and nutritional deficiencies are resolved.
Repeat endoscopy is not routinely necessary in patients who respond well clinically and in whom IgA-tTG has normalised.
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