Professor Andrew Day is an academic paediatric gastroenterologist based in Christchurch. After a period of training in Toronto, Canada, he took up a position at Sydney Children's Hospital, in Sydney, Australia. Returning to NZ in 2009 has a busy clinical role in Christchurch, and provides outreach Paediatric Gastroenterology services around the rest of the South Island.
He has strong clinical and research interests in coeliac disease as well as other gut disorders. Andrew’s ongoing research activities are supported by Cure Kids.
Professor Andrew Day presented at the Coeliac NZ Conference on the topic of "Management of non-responsive coeliac disease from a gastroenterologist and dietitians perspective"
The following questions arose from their presentation
What is the recommended follow-up after diagnosis?
There are various international recommendations as to the next follow-up after diagnosis of coeliac disease. Some of the key initial steps are education, support, establishing GFD, correcting micronutrient deficiencies (and documenting responses to this) and reviewing any associated issues. Most recommendations would support the first review around 6 months later with a check of GFD, documenting symptomatic improvements, reviewing nutritional status, checking antibody responses and reviewing for other issues. Beyond that, it is important to have an ongoing annual review with either a GP or specialist particularly if symptoms persist.
Do you think that aspects of the GCED resulted in inflammation ‘switch off’ like what has been seen in the Crohn's elimination diet?
The CDED is a very focused and restrictive diet that is aimed to enhance many aspects of gut health in people with Crohn's disease. It is based on several principles and data from various animal studies with support from general concepts. After its initial description in 2014, it has been more formally assessed concerning outcomes, however, the underlying mechanisms haven’t been fully elucidated or proven. The GCED is more directed towards coeliac disease
When do you see some of the new treatments for coeliac disease being available?
Hopefully, 1 or 2 treatments will be available in the next 3-5 years, and others to follow over the next 5-10 years. Unfortunately establishing whether a therapy is safe and effective does take a long time, with many checks and balances!
Newly diagnosed coeliac teenager & another teenager with Williams Syndrome (negative coeliac screen at diagnosis of WS at age 2). How often should they screen for coeliac disease?
Probably best to screen children at increased risk at 4-5 years, 7-8 years and then at 12-13 years of age even if no symptoms. And to recheck at any time before, between or after these ages if concerns/symptoms
How can we influence the Pharmac subsidy?
While it may not be successful, we are working on ways that we can promote the Pharmac criteria and/or other options.
If you have high alkaline phosphates that don’t lower post-diagnosis (13 years since diagnosis) and you are following a very strict diet (the entire house is gluten free), if osteopenia is not improving - is this normal?
Alkaline phosphatase can come from bones, the gut and the liver predominantly. It can be hard to interpret it in isolation (e.g. other liver tests or other bone assessments can help to work out what it is related to, and then guide what it means. Your doctor needs to consider the broad range of things that could lead to this.
What is known of the final trigger factors that result in onset, given the variable ages of onset?
The triggers for each person who develops coeliac disease aren’t always able to be worked out. Some known triggers include infections, however, gluten load and other dietary factors may also be contributory.
Presence of both DQ8 and DQ2 and severity of symptoms compared with one gene present?
There is a hierarchy of risk within the different genes. All the types/groupings are not the same.
Would you recommend genetic testing for HLA-DQ2&8 as part of the diagnosis with current testing?
No, this is not considered to be part of the standard workup in someone with possible coeliac disease. It doesn’t give any diagnostic value - it can only help to stratify risk
How do you safely introduce gluten to a 5-year-old who has been gluten-free since birth, and where there has been a strong coeliac presence in the family?
In general terms, a slow, gradual introduction of small amounts of gluten-containing food and then slowly building up to large quantities would be advisable. Be aware that the introduction of gluten may also increase other components of the diet such as fibre and fructan load (a fermentable CHO) which can also result in unrelated gut symptoms. Unfortunately delaying exposure to gluten in someone at increased risk of coeliac disease doesn’t reduce the risks for that person, it can only delay the onset of coeliac disease.
You mentioned self-testing. How do you do that?
There are home testing kits that can be purchased and used. They aren’t routinely recommended and are not covered cost wise. Further their validity can be variable depending on the expertise and experience of the user
The Gastric cardia Z line - what does the height of this indicate?
The Z line is another term for the junction between the lining of the oesophagus and the lining of the stomach
Does coeliac disease affect the spectrum or severity of perimenopausal symptoms?
Potentially, in some cases – althought it might depend on how well the coeliac disease is controlled.
Given the possibility of nutritional deficiency at diagnosis, does the panel advocate multi-vitamin supplementation, especially vitamin D, for the first few months?
No, it’s better to look for deficiencies and correct those that need it only.
Given the variability in pathology interpretation, why is villous flattening still considered the gold standard of diagnosis?
It is the next option that there is currently, but it does have limitations.
If one has genes for coeliac but has no CD, how likely is it to present later in life? can it be avoided?
Some studies show that most people will have antibodies present by their teenage years, although this is not the case for everyone. Always best to be cautious and recheck if symptoms persist or if there are other health concerns.
You mentioned coeliac disease can affect any organ. Generally speaking, can undiagnosed coeliac disease cause or trigger the onset of another autoimmune condition?
Coeliac is certainly linked with other autoimmune conditions, however, generally the younger one is at diagnosis the less likely that person is to get other problems. And the reverse also: later age of diagnosis associated with increased risk (longer time - more of these issues too)
If you were unable to attend the Coeliac NZ Conference and would like to access the video recordings of the presentations these can be purchased via the website for $40 (incl gst). See here for details.