Patients should be referred to a dietitian 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 normalization of immunoglobulin A-tissue transglutaminase (IgA-tTG) and mucosal healing. Complete mucosal recovery takes varying amounts of time; less than half of patients with celiac disease show normalization 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 serologic 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 titers 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 titer should normalize 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 titers at the time of diagnosis). No immediate action is required if the IgA-tTG titer 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 normalized.
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