Should Asymptomatic Patients Be Screened for Celiac?

Nurse practitioners and physician assistants working in retail clinics may not need to recommend celiac disease screening for patients lacking symptoms, including those at increased risk.

In a draft recommendation statement open for public comment until May 30, 2016, the US Preventive Services Task Force (USPSTF) stated it does not yet have enough evidence to justify recommending screening for celiac disease among asymptomatic patients.

In the statement, USPSTF said it didn’t find adequate evidence supporting the accuracy of celiac screening in asymptomatic patients. It also didn’t find sufficient evidence of efficacy for targeted screening in those at increased risk for celiac.

Some of the downsides to screening asymptomatic patients include false positives and unnecessary or inconclusive tests and biopsies. Anxiety and complications may also accompany these tests, especially invasive intestinal biopsies.

In addition, patients who receive a false positive may erroneously transition to a gluten-free diet, which could increase costs and burdens. Yet another potential concern is overdiagnosis of celiac disease.

“The USPSTF found inadequate evidence on the effectiveness of treatment of screen-detected, asymptomatic celiac disease to improve morbidity, mortality, or quality of life compared with no treatment or treatment initiated after clinical diagnosis,” the task force wrote.

It called for more studies that randomly assign patients to screening versus no screening in order to assess clinical outcomes, as well as more research on screening for targeted populations at risk for celiac disease.

“Treatment studies in screen-detected, asymptomatic persons are also needed to understand the effects of adherence to a gluten-free diet (compared with no dietary intervention), as well as the effects of immediate versus delayed dietary changes (eg, at the time of screen-detected diagnosis versus when symptoms develop),” the USPSTF stated.

Alice Bast, CEO of Beyond Celiac, a nonprofit focused on raising awareness of celiac disease, toldReutersthat insufficient data shouldn’t stop those at high risk for celiac from getting screened.

“The risk posed by the potential long-term health complications far outweighs the inconvenience and potential downsides,” Bast toldReuters.

The American College of Gastroenterology advises asymptomatic patients who have a first-degree relative with confirmed celiac disease to consider screening. Patients with type 1 diabetes might also want to get screened if they experience digestive symptoms similar to those of celiac disease.

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends that asymptomatic children with type 1 diabetes, autoimmune thyroiditis, Down syndrome, Turner syndrome, Williams syndrome, selective IgA deficiency, or a relative with celiac consider getting screened. The society advised that by age 3, asymptomatic children at risk for celiac could be tested.

In the United States, prevalence of celiac disease among adults is estimated to be about 0.40% to 0.95%. Nurse practitioners and physician assistants may find higher prevalence among white patients, those with a family history of celiac disease, and patients with other autoimmune diseases.

If patients with celiac consume dietary gluten (found in wheat, rye, and barley), they may experience inflammatory damage to the small intestine, which can cause gastrointestinal and nongastrointestinal illness.

The effect of celiac on patients varies, but the task force did recognize that “silent” celiac disease, or asymptomatic celiac disease, does exist. Some asymptomatic patients may exhibit signs of celiac disease, such as diarrhea, abdominal pain, weight loss, chronic fatigue, anemia, osteoporosis, and short stature.

The average age range for formal celiac disease diagnosis is 40 to 60 years.