Routine Screening of Celiac Disease Recommended for Type 1 Diabetics

Jill Stein

June 24, 2010

June 24, 2010 (San Diego, California) — Pediatric endocrinologists should regularly screen their type 1 diabetic patients for celiac disease, investigators advised here at ENDO 2010: The Endocrine Society 92nd Annual Meeting.

Importantly, the presence of symptoms should not be a prerequisite for screening, they said.

"Despite the fact that type 1 diabetics are at increased risk of celiac disease and that there are guidelines for screening from the American Diabetes Association, these have not filtered down to practicing endocrinologists very well," said Phyllis Speiser, MD, chief of the Division of Pediatric Endocrinology at North Shore–Long Island Jewish Health System in New Hyde Park, New York, in an interview with Medscape Diabetes & Endocrinology.

"At my institution, for example, there is a wide range of opinions among pediatric endocrinologists on when to screen and how to screen. . . . Awareness needs to be raised about this, especially to the fact that celiac disease patients don't have many obvious symptoms."

Dr. Speiser and her study coauthors reviewed the medical records of 532 consecutive patients with type 1 diabetes who presented to the pediatric endocrinology division at their institution over a recent 3-year period.

Overall, 493 patients (93% of the cohort) underwent celiac screening within roughly 3 months of being diagnosed with type 1 diabetes.

Results showed that 25 type 1 patients (5.1%) were seropositive for celiac disease on their initial testing. Of these, 11 patients (44%) had biopsy-proven celiac disease.

Of the 468 patients (94.9%) who were seronegative for celiac disease on their initial screening, 14 (5.4%) had a repeat positive screen, and 1 of these 14 patients was found to have biopsy-proven celiac disease 5 years after being diagnosed with type 1 diabetes. Seven other seropositive patients have not yet been biopsied.

Twelve type 1 diabetic patients (2.4%) had biopsy-proven celiac disease and were placed on a gluten-free diet.

Notably, about 58% of type 1 patients with biopsy-proven celiac disease were diagnosed with celiac disease more than 1 year, and sometimes as long as 10 years, after their type 1 diabetes diagnosis.

No type 1 diabetic patient with biopsy-proven celiac disease reported gastrointestinal (GI) symptoms before a definitive diagnosis had been established.

"This finding underscores the importance of not delaying screening for celiac disease until overt GI symptoms present," Dr. Speiser said.

On the basis of her study, she recommends that type 1 diabetics be screened for celiac disease as soon as they are diagnosed with diabetes.

How often should patients be screened? "Some patients develop celiac disease as long as 10 years after their diabetes diagnosis, so ongoing screening is essential, and we recommend screening once a year. Patients in whom a diagnosis of celiac disease is confirmed should be placed on a gluten-free diet and referred to a gastroenterologist."

"Prior research has shown that because of shared genetic predisposing traits, the prevalence of celiac disease is higher in type 1 diabetics, ranging from 1% to 16%, compared with 0.3% to 1% in the general population," Dr. Speiser pointed out.

Undiagnosed celiac disease might cause significant morbidity, she said. Short-term complications include growth disturbances, weight loss, and difficulty achieving glycemic control in type 1 diabetics. Long-term complications can include small bowel malignancy.

Dr. Speiser noted that although celiac disease is often asymptomatic, frequent episodes of symptomatic hypoglycemia can occur in type 1 diabetic patients within 6 months of the diagnosis of celiac disease.

"There is a well-known association between type 1 diabetes and celiac disease," James L. Rosenzweig, MD, an endocrinologist and associate professor of medicine at Boston University School of Medicine in Massachusetts, told Medscape Diabetes & Endocrinology. "Both are autoimmune diseases, and both are relatively common."

"Certainly, the study suggests that there is some benefit from screening diabetic children for celiac disease," he said. "A child with celiac disease who is slightly malnourished may have impaired growth and body development as a result. But should we routinely screen all pediatric diabetics for celiac disease? Even though initial screening would involve only a blood test, a blood test is an added test," and the costs add up. The results are interesting but I am not yet convinced, and I think that more studies in this area will be helpful."

Dr. Speiser and Dr. Rosenzweig have disclosed no relevant financial relationships.

ENDO 2010: The Endocrine Society 92nd Annual Meeting: Abstract P2-111. Presented June 20, 1020.

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