On March 28, The U.S. Preventive Services Task Force (USPSTF) published its final recommendation statement(www.uspreventiveservicestaskforce.org) and evidence summary(www.uspreventiveservicestaskforce.org) on screening for celiac disease in asymptomatic patients. In brief, that task force said more research is needed before recommending for or against screening -- an "I" statement.(www.uspreventiveservicestaskforce.org)
"This is not a recommendation against screening for celiac disease," says USPSTF member Ann Kurth, Ph.D., M.P.H., in a news bulletin.(www.uspreventiveservicestaskforce.org) "At this time, there simply is not enough evidence to determine the benefits and harms of screening for celiac disease in people without signs or symptoms of the condition, so the task force is calling for more research. Clinicians should use their judgment when deciding whom to screen."
This is the first time the task force has reviewed the available evidence and made a statement on screening for celiac disease. The recommendation does not apply to patients with symptoms of celiac disease, such as diarrhea, abdominal pain and unexplained weight loss.
The AAFP released its own final recommendation, which mirrors the USPSTF's guidance.
- On March 28, The U.S. Preventive Services Task Force published its final recommendation statement and evidence summary on screening for celiac disease in asymptomatic patients, saying more research is needed before it could recommending for or against screening.
- This is the first time the task force has reviewed the available evidence and made a statement on screening for celiac disease.
- The AAFP released its own final recommendation, which mirrors the USPSTF's guidance.
In its statement, the USPSTF highlighted areas of research on celiac disease that could better inform future recommendations for screening patients. Specifically, the task force called for research into
- the effectiveness of targeted screening in patients at increased risk for celiac disease;
- the accuracy of serological markers in asymptomatic patients, particularly those with risk factors for the disease;
- the effect of treatment for celiac disease in asymptomatic patients who have positive blood tests for the disease; and
- clinical outcomes, such as changes in health and quality of life, among people who receive screening versus those who do not.
Response to Public Comment
A draft version of this recommendation statement was posted for public comment on the USPSTF website from May 3-30, 2016.
A number of commenters described personal experiences of patients whose celiac disease diagnosis was delayed because they demonstrated atypical or nonspecific symptoms.
In response, the USPSTF expanded the "Suggestions for Practice" section of the recommendation statement to highlight nonclassical symptoms such as anemia and osteoporosis and how they might lead to delayed diagnosis.
Another common concern among commenters was the higher risk for celiac disease seen among patients with relatives who have the condition and patients with other autoimmune diseases. In turn, the task force revised the "Research Needs and Gaps" section to emphasize the importance of developing evidence to guide clinical practice for this population.
Scope of Review
The USPSTF reviewed evidence on the accuracy of screening in asymptomatic adults, adolescents and children; the potential benefits and harms of screening versus not screening, as well as targeted versus universal screening; and the benefits and harms of treating screen-detected celiac disease. For questions regarding the benefits and harms of screening and treatment, outcomes of interest included morbidity, mortality and quality of life.
The task force also reviewed contextual information on the prevalence of celiac disease among patients without overt symptoms and the natural history of subclinical and silent celiac disease.
A recent good-quality systematic review on the accuracy of diagnostic tests for celiac disease, which included studies of patients with symptoms, as well as those in whom symptom status was not described, found high strength of evidence that immunoglobulin A (IgA) tissue transglutaminase (tTG) testing was associated with high (greater than 90 percent) sensitivity and specificity, and IgA endomysial antibody (EMA) tests were associated with high specificity, based on consistent results from prior systematic reviews and new studies.
The systematic review included only two small, fair-quality studies reporting diagnostic accuracy in asymptomatic patients at increased risk for celiac disease. These cross-sectional studies, both of which were conducted outside the United States, found lower sensitivity (range, 57 percent to 71 percent) for immunoglobulin G (IgG) tTG, IgA tTG and IgA EMA tests compared to studies that were not restricted to asymptomatic patients; specificity ranged from 83 percent to 98 percent.
The USPSTF said it did not review evidence on nonceliac gluten sensitivity because the condition is defined based on the presence of symptoms rather than diagnostic test results, and it is not known to lead to health complications associated with celiac disease.
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American Family Physician: Celiac Disease: Diagnosis and Management