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At the heart of general practice since 1960

GP workload fear on renal disease

Dr Sohail Butt explains how he ensures this group of patients receive optimal care through a simple annual health check

‘This increase in prevalence since 1998 is probably due to us being increasingly aware of the disease'

Clinical studies suggest 20-25 per cent of diagnosed coeliac patients fail to keep to a strict gluten-free diet, and so are at increased risks of complications.

Compliance with the gluten-free diet has been shown to improve with medical follow-up, and the British Society Of Gastroenterology guidelines suggest patients be reviewed at least annually, either in primary or secondary care.

Identifying patients

Each September I search the EMIS database for patients with coeliac disease. I review the patient records as there are sometimes one or two incorrect codings.

Each September the practice invites all the coeliac patients for an annual review, suggesting they come to any surgery during October. This allows patients to fit their review in around holiday, family and work commitments, and also ensures I have the relevant pathology forms and information sheets to hand. At the clinic I see patients during a routine 10-minute consultation.

Tests and checks

Patients are asked about dietary compliance and symptoms, have their height and weight checked, and blood taken for FBC, folate, alkaline phosphatase, and tissue transglutaminase antibodies. Tissue transglutaminase antibodies can be used to assess dietary compliance as they are raised in coeliacs taking significant amounts of gluten in their

diet. I arrange a review with a dietitian for patients requiring dietary advice.

As patients have an increased risk of osteoporosis I follow the Primary Care Society for Gastroenterology guidelines, which suggest coeliac patients should have a DEXA scan at the time of diagnosis, which is then repeated:

• at the menopause for women

• at age 55 for men

• at any age should a fragility fracture occur.

Keeping to the gluten-free diet leads to improved bone mineral density of most coeliac patients.

Coeliac patients may have hyposplenism, which predisposes them to this serious pneumococcal infection. Hence, I follow the Department of Health advice and consider prophylatic immunisation against the pneumoccocus in all my coeliac patients over two years of age.

There is an increased risk of coeliac disease in first-degree family members of affected people, so I advise patients that relatives should be assessed if they develop suggestive symptoms.

Prescription review

I review the repeat prescriptions. These are usually kept to a manageable length by the EMIS prescribing setting, which deletes any item not requested for one year. There are now prescribing guidelines which I find useful when setting up and reviewing gluten-free foods, which are prescribable as an ACBS. These are available on the internet at www.bspghan.org.uk/working_groups/coeliac.shtml

We use a template on EMIS to record the information in a standardised way, which facilitates research and audit (see box above).

I have patient information leaflets to give on the gluten-free diet and member-ship of Coeliac UK – the national patient support group, online at www.coeliac.co.uk

If patients have unexplained weight loss, unexplained abdominal pain, diarrhoea or rectal bleeding on the gluten-free diet, I consider referral to the gastroenterologist for review.

Results

In the past 12 months, 19 patients with coeliac disease had an annual review at the practice.

All of them were compliant with the gluten-free diet. In June 2005, we had 29 patients with coeliac disease from a population of 15,300.

In 1998 I carried out an audit of coeliac care in our 15,500 patients and found 18 patients with coeliac disease, of which only seven had received structured follow-up care.

This increase in prevalence since 1998 is probably due to my GP colleagues increasingly being aware of the varied presentation of coeliac disease and wider availabilty to GPs of serological tests for assessing patients with suggestive symptoms.

Coeliac clinic template

Gluten-free diet Yes

Number of lapses from diet

a month 3

Abdominal pain No

Weight 70kg

Height 170cm

Body mass index 24.2

Hb 13.2g/l

Red cell folate 200

Serum B12 430

Serum folate 110

Endomysial antibody Negative

Pneumococcal vaccination Aug 1999

At risk of osteoporosis Yes

Action taken DEXA arranged, advice on diet

Family counselling yes

Action taken Patient will discuss with family

Seen by dietitian Yes

Action taken Advised to increase dietary calcium

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