Red Flags
- Coeliac crisis — severe diarrhoea, dehydration, electrolyte derangement, weight loss, hypoalbuminaemia — admit; IV correction; gluten-free diet[1]
- Refractory coeliac disease (persistent symptoms despite strict gluten-free diet) — gastroenterology; rule out enteropathy-associated T-cell lymphoma (EATL)[1]
- First-degree relatives of confirmed cases — serological screening (10% prevalence vs 1% general)[1]
- Iron deficiency anaemia or osteoporosis without obvious cause — investigate for coeliac disease (atypical presentation)[1]
First-line treatment
Interventions
- Strict lifelong gluten-free diet[1]Cornerstone treatment; eliminate wheat, barley, rye and contaminated oats. Dietitian referral mandatory; symptoms typically resolve within 6–12 months; mucosal recovery 1–2 years
- Vitamin and mineral replacement[1]Iron, calcium, vitamin D, B12, folate, zinc as indicated by deficiencies; check fat-soluble vitamins (A, D, E, K) in severe disease
- Pneumococcal and influenza vaccination[1]Functional hyposplenism in coeliac disease; vaccinate against encapsulated organisms
- Annual review[1]Symptom assessment, dietary adherence (anti-tTG decline), bone health, growth in children, screening for autoimmune comorbidities (T1DM, autoimmune thyroid)
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Iron supplementation[1] | Iron salt or IV iron | Ferrous sulfate 200 mg PO BD or IV iron if poor absorption / intolerance / severe anaemia | 3–6 mg/kg/day elemental iron | Most patients have iron deficiency at diagnosis; gluten-free diet does not always restore mucosal absorption rapidly |
| Cholecalciferol (vitamin D)[1] | Vitamin | 1000–4000 IU PO daily (loading 60,000 IU weekly × 8 weeks if deficient) | 400–1000 IU daily | Common deficiency; also addresses osteoporosis risk |
| Budesonide (refractory coeliac)[1] | Topically active glucocorticoid | 9 mg PO once daily, taper as response permits | — | Refractory coeliac type 1 not responding to gluten-free diet; specialist initiation |
Iron supplementation[1]
Iron salt or IV iron
- Adult
- Ferrous sulfate 200 mg PO BD or IV iron if poor absorption / intolerance / severe anaemia
- Paediatric
- 3–6 mg/kg/day elemental iron
Most patients have iron deficiency at diagnosis; gluten-free diet does not always restore mucosal absorption rapidly
Cholecalciferol (vitamin D)[1]
Vitamin
- Adult
- 1000–4000 IU PO daily (loading 60,000 IU weekly × 8 weeks if deficient)
- Paediatric
- 400–1000 IU daily
Common deficiency; also addresses osteoporosis risk
Budesonide (refractory coeliac)[1]
Topically active glucocorticoid
- Adult
- 9 mg PO once daily, taper as response permits
- Paediatric
- —
Refractory coeliac type 1 not responding to gluten-free diet; specialist initiation
Safety-net
- Strict gluten avoidance is lifelong — even small accidental exposure causes mucosal damage and symptoms[1]
- Read all food labels carefully; check medications and supplements for hidden gluten; cross-contamination at home and restaurants is common[1]
- Tell first-degree relatives — they have 10% lifetime risk and should consider serological screening[1]
Referral criteria
- Coeliac crisis with severe dehydrationHospital admission for IV correction[1]
- Persistent symptoms despite strict gluten-free diet for >6 monthsGastroenterology for refractory coeliac and EATL workup[1]
- New diagnosis of coeliacGastroenterology + dietitian + bone health team[1]
- Coeliac with iron deficiency or osteoporosis at diagnosisEndocrinology / haematology for parallel management[1]
Clinical summary
Diagnosis and management of coeliac disease — serology + duodenal biopsy diagnostic pathway with strict lifelong gluten-free diet.