Is Celiac Screening for Kids With Type 1 Diabetes Adequate?

Miriam E. Tucker

June 14, 2014

SAN FRANCISCO — Current guidelines for celiac disease screening in patients with type 1 diabetes may miss a significant proportion of asymptomatic cases, a new study suggests.

The findings were presented here at the American Diabetes Association (ADA) 2014 Scientific Sessions by Evan Graber, DO, a fellow in pediatric endocrinology at Mount Sinai School of Medicine, New York.

Because the prevalence of celiac disease is higher in children with type 1 diabetes than in the general population and celiac disease is often asymptomatic, ADA guidelines state that children with type 1 diabetes should be screened for the condition "soon after" diagnosis. The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends celiac screening "at diagnosis and then annually for 5 years."

But in a retrospective chart review of 340 pediatric patients with type 1 diabetes who were screened at diagnosis and/or yearly for celiac antibodies, Dr. Graber and colleagues found that a third of those with positive antibodies were not detected until after 5 years past diagnosis.

"These data are more in line with the ISPAD rather than ADA guidelines. Therefore, revision of screening guidelines may be needed to include more frequent screening in the first 5 years after type 1 diagnosis and beyond 5 years," Dr. Graber said in his presentation.

Identifying celiac disease in patients who don't have symptoms is important because emerging data suggest that among people with biopsy-confirmed disease, even those who weren't aware of clinical symptoms report feeling better — ie, with less abdominal pain and bloating — when they follow gluten-free diets, Dr. Graber told Medscape Medical News in an interview.

And, he added, there are also concerns about long-term risk for complications such as gastrointestinal lymphoma, poor growth, and iron-deficiency anemia in kids with unrecognized celiac disease. "So that's what we're really trying to avoid," he said.

But screening every type 1 patient presents a clinical challenge, session moderator Michael Haller, MD, associate professor of pediatrics at the University of Florida, Gainesville, told Medscape Medical News in an interview.

While he acknowledged that there could be long-term benefits to treating even asymptomatic patients with a gluten-free diet if they truly have celiac disease, "on the other hand, some people would argue that if they're clinically unaffected, they're growing fine…their diabetes is well-controlled," why intervene, he said.

"I think the question is really about how to apply it clinically," he added. Physicians are often confused about whether or not to screen in their own practices "because the frequency of finding folks with positive antibodies who are unaffected by the disease is pretty high, and a lot of those families choose not to go forward with biopsies or follow a gluten-free diet. It makes it challenging for a treating physician to know the best thing to do for the patient if you're not going to do anything about the information."

Most With Celiac Were Asymptomatic

Of the total 340 patients screened by Dr. Graber and colleagues, 9.7% (33) were positive for celiac disease antibodies (antitissue transglutaminase, antiendomysial, or antigliadin antibodies). Nearly three-quarters of those were female.

Of the 33 with positive antibodies, 22 (67%) were detected between the time they were diagnosed with diabetes and 5 years later, while the antibodies were detected more than 5 years out in the other 11 (33%).

Twenty of the 33 with positive antibodies underwent biopsy to confirm the celiac diagnosis, and 12 (9 female) had positive biopsies within a mean of 3.2 years following type 1 diabetes diagnosis. Of those 12, biopsy confirmation of celiac disease was within 1 year of diabetes diagnosis for 3 patients and more than 5 years after diagnosis for another 3.

Most patients did not have symptoms of celiac disease, and none of the patients with biopsy-confirmed disease had high clinical suspicion prior to diagnosis, Dr. Graber noted.

What Should the Guidelines Say?

Both Dr. Graber and Dr. Haller agree that these data don't point to easy recommendations.

Dr. Graber told Medscape Medical News, "It's hard to say what the ideal guideline is. Our institution does annual screening. ISPAD says to screen within the first 5 years. I would agree with that. But it's difficult once you talk about the cost/benefit ratio."

Dr. Haller added, "You can make an argument either way. There's a high likelihood we're missing patients who have clinically relevant celiac disease out there because we don't screen enough. On the other hand, if you screen everybody you're going to spend a lot of money screening and not pick up patients with clinically relevant disease.

"It's a problem with all screening programs. You have to decide where the level is to make the cutoff. I think at the end of the day it has to be the physician and the patient who decide how relevant that diagnosis might be for them," he concluded.

Dr. Graber and Dr. Haller have reported no relevant financial relationships .

American Diabetes Association 2014 Scientific Sessions; June 13, 2014. Abstract 30-OR

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