Coeliac disease

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]

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)

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

Refractory coeliac type 1 not responding to gluten-free diet; specialist initiation

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]

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]

Diagnosis and management of coeliac disease — serology + duodenal biopsy diagnostic pathway with strict lifelong gluten-free diet.

1.ACG Clinical Guideline: Diagnosis and Management of Celiac Disease (2023); ESPGHAN Guidelines for Diagnosis 2020 (2023)