Monitoring

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.[107] 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.[142] Symptoms are poor predictors of mucosal inflammation or recovery.[143]

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.[23]

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.[23][108] In most patients, IgA-tTG titer should normalize within 6 to 9 months,[144] 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).[145][146] 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. 

Bone mineral density may be assessed in adults at the time of diagnosis, or after they have been on a gluten-free diet for 1 year.[23][55][137][138][147][148]

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