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Current challenges in the management of coeliac disease
Dr Jeremy Woodward trained in Cambridge and London and completed a PhD in immunology in Birmingham prior to his appointment as a consultant gastroenterologist at Addenbrooke’s Hospital, Cambridge in 2002. He is the lead clinician for nutrition and chairs the Trust nutrition steering group. His research interests include intestinal failure, transplantation and coeliac disease.
Guidelines on the diagnosis and management of coeliac disease have been issued recently by the British Society of Gastroenterology and the National Institute of Health and Care Excellence. Despite valiant attempts to produce evidence based guidance, the existing evidence base is weak and there is little on which to support firm recommendations. Key deficiencies remain in a number of fundamental areas. Our current tests for the diagnosis of coeliac disease do not provide the degree of certainty that was once believed and misdiagnosis is common. The significance of subthreshold diagnostic tests is unclear, and with wider acceptance of non coeliac gluten sensitivity as an entity it is becoming apparent that the current paradigm for the definition of coeliac disease is itself problematic. The management of coeliac disease after diagnosis is flawed by the lack of appropriate outcomes or endpoints which in turn leads to lack of uniformity in process and quality of follow up as well as the current recommendations for indefinite annual review which are challenging to implement. Whilst new developments may lead us to more robust criteria for diagnosis and follow up, there is a clear need for generating better outcome measures that allow us to define and refine pathways for diagnosis and care.