This study shows the rising incidence of paediatric coeliac disease within southeast Scotland, this was supported by funding from Coeliac UK.

The rising incidence of coeliac disease in Scotland.

Abstract

Although the incidence of pediatric celiac disease (CD) is increasing globally, it is uncertain whether this is attributed to improved case ascertainment or signifies a true rise. We aimed to identify all incident cases of childhood CD in southeast Scotland over the period 1990 to 2009 to assess trends in total incidence and cases diagnosed as a result of (1) a classic presentation, (2) a nonclassic presentation, or (3) targeted screening.

Twenty-year retrospective cohort study of case notes, pathology databases, endoscopy, and patient records for all children ( 000-233 000). Data were age-gender standardized and Poisson regression models used to calculate changes in incidence over time.

A total of 266 children were diagnosed from 1990 to 2009 with an increase in incidence from 1.8/100 000 (95% confidence interval [CI] 1.1-2.7) to 11.7/100 000 (95% CI 9.8-13.9) between the epochs 1990 to 1994 and 2005 to 2009, respectively (P < .0001). The incidence of nonclassic presentation (children with a monosymptomatic presentation and those with extraintestinal symptoms) and actively screened cases increased by 1566% (P < .05) and 1170% (P < .001) from 1990 to 1999 to 2000 to 2009, respectively. However, a rise in the incidence of Oslo classic cases from 1.51/100 000 (95% CI 0.91-2.38) in 1990 to 1994 to 5.22/100 000 (95% CI 3.98-6.75) in 2005 to 2009 (P < .01) remained evident.

The incidence of pediatric CD increased 6.4-fold over the 20 years. This study demonstrates that this rise is significant for classic CD, indicating a true rise in the incidence of pediatric CD.

Reference

White, L.E., et al. (2013). The rising incidence of celiac disease in Scotland. Pediatrics, 132 1-8

Comment

The paper by White et al (2013) suggests that the incidence of coeliac disease has been increasing within the paediatric population within southeast Scotland. However, research cannot yet explain the reasons behind the increasing frequency of diagnosis of coeliac disease. There is some suggestion that this may be related to increased awareness and improvements in diagnosis. Therefore, further research is needed to continue to explore the epidemiology of coeliac disease. Sarah Sleet, Chief Executive of Coeliac UK says “It is important that more research is undertaken to establish the scale of any increase and the important public health implications of such a finding”

Related references

Logan, R.F., et al. (1986). Prevalence and “incidence” of celiac disease in Edinburgh and the Lothian region of Scotland. Gastroenterology, 90(2) 334-342

This study explores immunoglobulin A deficiency in individuals with Type 1 diabetes and/or coeliac disease in comparison to the general population.

Serological testing for coeliac disease in Type 1 diabetes mellitus: is immunoglobulin A level measurement necessary?

Abstract

Immunoglobulin A (IgA) measurement is advocated when case finding for coeliac disease in patients with Type 1 diabetes mellitus. Currently there is a paucity of contemporary studies assessing IgA deficiency in Type 1 diabetes. This study evaluates the prevalence of IgA deficiency in individuals with Type 1 diabetes, compared with patients with coeliac disease and control subjects. In addition, we evaluate whether routine IgA measurement is justifiable when case finding for coeliac patients with Type 1 diabetes.

All patients were assessed using IgA endomysial antibodies, IgA anti-tissue transglutaminase antibodies and total IgA levels. Altogether, 2434 individuals were tested: 1000 patients with Type 1 diabetes, 234 patients with coeliac disease and 1200 population control subjects. Definative IgA deficiency was defined as total IgA levels <0.07g/l.

The prevalence of IgA deficiency was significantly more common in patients with Type 1 diabetes (0.9%, n=9/1000; P = 0.036) and coeliac disease (1.29%, n=3/234; P = 0.041) when compared with population control subjects (prevalence of 0.17%, 2/1200).There was no statistical difference for IgA deficiency between Type 1 diabetes and coeliac disease (P = 0.87). Of patients in the group with Type 1 diabetes, 3.3% (33/1000) had coeliac disease, and of those only one patient had IgA deficiency leading to an antibody-negative presentation. Both IgA-deficient individuals within the population control subjects had normal duodenal biopsies and no relevant symptoms.

IgA deficiency is more common in Type 1 diabetes compared with population control subjects. Despite this, very few individuals with Type 1 diabetes and IgA deficiency appear to have villious atrophy on biopsy. These outcomes question the practice of routine IgA measurement when case finding for coeliac patients with Type 1 diabetes.

Reference

Kurien M et al. (2013). Serological testing for coeliac disease in Type 1 diabetes mellitus: is immunoglobulin A level measurement necessary? Diabetic Medicine, 30 840-845

Comment

This study, alongside previous research, shows that immunoglobulin A deficiency was higher in individuals with Type 1 diabetes and in those with coeliac disease when compared to the general population. This study has the benefit of using a large sample with a control group to explore this. However, genetic factors were not explored, which may have provided further benefit to understanding.

This study also found that within IgA deficient individuals with Type 1 diabetes, villous atrophy at biopsy was uncommon. This finding is similar to a previous study carried out within an Austrian paediatric population by Schober et al. (2000), who similarly found that normal biopsies were found within individuals with Type 1 diabetes and IgA deficiency. This suggests that additional research using a large multicentre sample would be required to explore this finding further. Subsequent to this, discussions should continue to explore the role of IgA measurement to identify coeliac disease in individuals with Type 1 diabetes.

The National Institute for Health and Care Excellence (2009) guideline for adults suspected of having coeliac disease, recommends the first choice blood test to be the IgA tissue transglutaminase antibody (tTGA) and sometimes the IgA endomysial (EMA). If an individual is IgA deficient this may cause a false negative result and then the IgG tTGA or IgG EMA tests may be used (NICE 2009). These tests have adequate sensitivity and specificity, to be considered alongside histology, as the small bowel biopsy is the gold standard for the diagnosis of coeliac disease (NICE 2009).

Related references

National Institute for Health and Care Excellance (2009) Recognition and assessment of coeliac disease. http://www.nice.org.uk/cg86

Schober et al (2000) Screening by anti-endomysium antibody for celiac disease in diabetic children and adolescents in Austria. J Pediatr Gastroenterol Nutri, 30(4) 391-6