Serological Testing for Coeliac Disease in Patients With Symptoms of Irritable Bowel Syndrome: A Cost-Effectiveness Analysis

S.M. Mein; U. Ladabaum

Disclosures

Aliment Pharmacol Ther. 2004;19(11) 

In This Article

Summary and Introduction

Background: Patients diagnosed with irritable bowel syndrome may have coeliac disease.
Aim: To evaluate the cost-effectiveness of coeliac disease testing in suspected irritable bowel syndrome.
Methods: We used decision analysis to estimate the number of coeliac disease cases detected, quality-adjusted life-years gained, and costs resulting from testing suspected irritable bowel syndrome patients for tissue transglutaminase antibody or an antibody panel (tissue transglutaminase, gliadin, total immunoglobulin A). Positive tests prompted endoscopic biopsy. A gluten-free diet improved quality of life in coeliac disease.
Results: Assuming a coeliac disease prevalence of 3%, tissue transglutaminase detected 28 and the panel detected 29 of 30 coeliac disease cases among 1000 suspected irritable bowel syndrome patients. The cost/case detected was $4600 with tissue transglutaminase and $8800 with the panel. The cost/quality-adjusted life-year gained with tissue transglutaminase was $7400, and the incremental cost/quality-adjusted life-year gained for the panel vs. tissue transglutaminase was $287 000. Tissue transglutaminase cost under $100 000/quality-adjusted life-year gained at a coeliac disease prevalence ≥1.1%, assuming a modest utility gain of 0.005 with coeliac disease diagnosis.
Conclusions: Testing for coeliac disease in patients with suspected irritable bowel syndrome is likely to be cost-effective even at a relatively low coeliac disease prevalence and with small improvements in quality of life with a gluten-free diet.

Clinicians evaluating patients with abdominal pain and altered defecation must decide which tests to perform before making management recommendations. These symptoms are characteristic of the irritable bowel syndrome (IBS), which affects 9-22% of the United States population[1] at an estimated direct cost of $1.4 billion and indirect cost of $205 million per year.[2] While IBS is not life-threatening, it has a significant impact on quality of life.[3,4,5]

Although the recent trend has been to consider IBS a condition that can be diagnosed based on symptom criteria, as opposed to regarding it as a 'diagnosis of exclusion' only to be made after extensive testing, a limited screen for other diseases is recommended in patients with symptoms suggestive of IBS.[6,7,8] The yield of haematology, chemistry and thyroid function tests, sigmoidoscopy or colonoscopy, and microbiological stool studies in patients with 'suspected' IBS ('s'-IBS) is modest.[6] In contrast, recent studies suggest that the prevalence of coeliac disease, a gluten-sensitive enteropathy characterized by intestinal villous blunting and malabsorption,[9] is 3-11%[10,11,12] among patients diagnosed with IBS, compared with 0.02-0.65%[9,10,11,12,13] in the general population. Coeliac disease may be present in patients with IBS-like symptoms and diarrhoea or constipation predominance, or alternating bowel habit.[10,11]

While a classic presentation of coeliac disease consists of steatorrhea and weight loss, the presentation can be more subtle, including symptoms characteristic of IBS (abdominal discomfort, altered defecation, bloating, gas), and diagnosis can be delayed.[14,15] The classic presentation of coeliac disease seems to account for a diminishing fraction of cases.[16,17] In recent reports, 24-37% of coeliac disease patients were initially diagnosed with IBS.[14,15,18] Whereas IBS is a chronic condition with no cure and with limited therapeutic options, adherence to a gluten-free diet may improve quality of life and prevent long-term complications in coeliac disease.[9,18,19,20,21,22,23,24,25]

It has been suggested that patients with 's'-IBS should be tested for coeliac disease.[6,10,11] Our aims were to estimate the potential clinical and economic consequences of coeliac disease testing in patients with 's'-IBS. We constructed a decision analytic model to explore the number of cases of coeliac disease that might be uncovered by competing serological testing strategies or up-front small bowel biopsy in a population of patients with 's'-IBS, the associated gains in quality-adjusted life-years (QALYs), and the costs per case detected and QALYs gained.

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