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.[150] Complete mucosal recovery takes varying amounts of time; less than half of the 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.[193] Symptoms are poor predictors of mucosal inflammation or recovery.[194]

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.[34]​ The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition has recommended regular follow-ups in children with established celiac disease diagnosis, with the first follow-up scheduled 3-6 months after diagnosis and subsequent visits every 6 months until normalization of tTG levels and every 12-24 months thereafter.[195]

Patients should be prescribed oral supplementation to treat any nutritional deficiencies present at diagnosis, and should be monitored until deficiencies are resolved. Most nutritional deficiencies improve on a gluten-free diet, but some take longer than others to resolve (such as iron, zinc).[196][197]​ Some new nutritional deficiencies may appear on a gluten-free diet, such as vitamin B6 deficiency.[196]

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.[34][151]​ In most patients, IgA-tTG titer should normalize within 6-9 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).[198][199][200]​ No immediate action is required if the IgA-tTG titer is trending down, the patient is asymptomatic, and nutritional deficiencies are resolved. 

Repeat endoscopy can be offered as part of a shared decision-making process with the patient 2 years after the diagnosis, to identify gluten exposures, even in the face of a normalized IgA-tTG, and to stratify risk for complications, as the risk of cancer and bone disease is mostly linked to persistent villous atrophy.[70][150][201]

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.[34][137][189][202][203]

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