Celiac Disease: Ten Things That Every Gastroenterologist Should Know

Amy S. Oxentenko; Joseph A. Murray


Clin Gastroenterol Hepatol. 2015;13(8):1396-1404. 

In This Article

6. How Is Celiac Disease Managed?

A strict, lifelong GFD, avoiding wheat, rye, and barley, remains the treatment of CD.[3] How much is too much? Although the maximum safe amount of gluten for patients with CD is unknown, <10 mg daily of gluten is probably safe in preventing ongoing intestinal injury. For foods to be labeled as gluten-free, the Food and Drug Administration requires there be <20 parts per million of gluten in the product;[44] however, restaurants and foods with meat, poultry, and eggs are not covered by these regulations.

Previously, patients with CD were advised to avoid oats because of cross-contact or cross-sensitivity. Oat avoidance limits food choices.[45] Oats belong to the same subfamily as wheat, rye, and barley but to a different tribe and contain very few deleterious peptides. Cross-sensitivity to oats may occur in highly sensitive patients, but it is rare. Initial avoidance of oats should be considered in newly diagnosed CD with severe malabsorption, with reintroduction after 1 year when symptom-free. Cross-contact of oats with gluten-containing grains occurs. For patients doing well on a GFD, pure oats can be consumed in moderation, but if symptoms recur or serologic titers rise, then withhold oats.[3]

All patients with CD should be referred to a dietitian well-versed in a GFD. Guidelines are now available for dietitians to follow in regard to assessing patients with CD.[46] If left to research a GFD on their own, patients encounter misinformation[47] and may unnecessarily restrict intake. Other practical topics addressed by dietitians include how to avoid cross-contact at home (eg, separate toasters or jars of spread), travel and restaurant tips, and reliable information on the Internet. In addition, it is necessary to review the overall health of a patient's GFD, because obesity, diabetes, and other comorbidities are increasingly common.[48]

Patients with CD should have all medications and supplements reviewed by a pharmacist to ensure that they are gluten-free,[49] recognizing this may be manufacturer-dependent. Food and Drug Administration food labeling rules do not apply to medications.

Practical Suggestion

All patients should follow a strict, lifelong GFD avoiding wheat, rye, and barley. All patients should be counseled on a GFD by an expert dietitian, and a pharmacist should review all medications and supplements. Oats should be eliminated for the first year in patients with significant features of disease and only gluten-free oats reintroduced later if well controlled.