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Early management of patients with acute ischemic stroke
(AIS). Conceptually, early management can be separated into initial triage and decisions about intervention to restore blood flow with thrombolysis or mechanical thrombectomy. If reperfusion therapy is not appropriate, then the focus is on management to minimize further damage from the stroke, decrease the likelihood of recurrence, and lessen secondary problems related to the stroke.
All patients with AIS should receive noncontrast CT to determine if there is evidence of a hemorrhagic stroke and, if such evidence exists, than the patient is not a candidate for thrombolysis. Intravenous alteplase should be considered for patients who present within 3 hours of stroke onset and for selected patients presenting between 3-4.5 hours after stroke onset (for more details, see Table 6 in the guidelines). Selected patients with AIS who present within 6-24 hours of last time they were known to be normal and who have large vessel occlusion in the anterior circulation, may be candidates for mechanical thrombectomy in specialized centers. Patients who are not candidates for acute interventions should then be managed according to early stroke management guidelines.
Early stroke management for patients with AIS admitted to medical floors involves attention to blood pressure, glucose, and antiplatelet therapy. For patients with blood pressure lower than 220/120 mm Hg who did not receive IV alteplase or thrombectomy, treatment of hypertension in the first 48-72 hours after an AIS does not change the outcome. It is reasonable when patients have BP greater than or equal to 220/120 mm Hg, to lower blood pressure by 15% during the first 24 hours after onset of stroke. Starting or restarting antihypertensive therapy during hospitalization in patients with blood pressure higher than 140/90 mm Hg who are neurologically stable improves long-term blood pressure control and is considered a reasonable strategy.
For patients with noncardioembolic AIS, the use of antiplatelet agents rather than oral anticoagulation is recommended. Patients should be treated with aspirin 160 mg-325 mg within 24-48 hours of presentation. In patients unsafe or unable to swallow, rectal or nasogastric administration is recommended. In patients with minor stroke, 21 days of dual-antiplatelet therapy (aspirin and clopidogrel) started within 24 hours can decrease stroke recurrence for the first 90 days after a stroke. This recommendation is based on a single study, the CHANCE trial, in a homogeneous population in China, and its generalizability is not known. If a patient had an AIS while already on aspirin, there is some evidence supporting a decreased risk of major cardiovascular events and recurrent stroke in patients switching to an alternative antiplatelet agent or combination antiplatelet therapy. Because of methodologic issues in the those studies, the guideline concludes that, for those already on aspirin, it is of unclear benefit to increase the dose of aspirin, switch to a different antiplatelet agent, or add a second antiplatelet agent. Switching to warfarin is not beneficial for secondary stroke prevention. High-dose statin therapy should be initiated. For patients with AIS in the setting of atrial fibrillation, oral anticoagulation can be started within 4-14 days after the stroke. One study showed that anticoagulation should not be started before 4 days after the stroke, with a hazard ratio of 0.53 for starting anticoagulation at 4-14 days, compared with less than 4 days.
Hyperglycemia should be controlled to a range of 140-180 mg/dL, because higher values are associated with worse outcomes. Oxygen should be used if needed to maintain oxygen saturation greater than 94%. High-intensity statin therapy should be used, and smoking cessation is strongly encouraged for those who use tobacco, with avoidance of secondhand smoke whenever possible.
Patients should be screened for dysphagia before taking anything per oral, including medications. A nasogastric tube may be considered within the first 7 days, if patients are dysphagic. Oral hygiene protocols may include antibacterial mouth rinse, systematic oral care, and decontamination gel to decrease the risk of pneumonia .
For deep vein thrombosis prophylaxis, intermittent pneumatic compression, in addition to the aspirin that a patient is on is reasonable, and the benefit of prophylactic-dose subcutaneous heparin (unfractionated heparin or low-molecular-weight heparin) in immobile patients with AIS is not well established.
In the poststroke setting, patients should be screened for depression and, if appropriate, treated with antidepressants. Regular skin assessments are recommended with objective scales, and skin friction and pressure should be actively minimized with regular turning, good skin hygiene, and use of specialized mattresses, wheelchair cushions, and seating until mobility returns. Early rehabilitation for hospitalized stroke patients should be provided, but high-dose, very-early mobilization within 24 hours of stroke should not be done because it reduces the odds of a favorable outcome at 3 months.
Completing the diagnostic evaluation for the cause of stroke and decreasing the chance of future strokes should be part of the initial hospitalization. While MRI is more sensitive than is CT for detecting AIS, routine use of MRI in all patients with AIS is not cost effective and therefore is not recommended. For patients with nondisabling AIS in the carotid territory and who are candidates for carotid endarterectomy or stenting, noninvasive imaging of the cervical vessels should be performed within 24 hours of admission, with plans for carotid revascularization between 48 hours and 7 days if indicated. Cardiac monitoring for at least the first 24 hours of admission should be performed, while primarily looking for atrial fibrillation as a cause of stroke. In some patients, prolonged cardiac monitoring may be reasonable. With prolonged cardiac monitoring, atrial fibrillation is newly detected in nearly a quarter of patients with stroke or TIA, but the effect on outcomes is uncertain. Routine use of echocardiography is not recommended but may be done in selected patients. All patients should be screened for diabetes. It is not clear whether screening for thrombophilic states is useful.
All patients should be counseled on stroke, and provided education about it and how it will affect their lives. Following their acute medical stay, all patients will benefit from rehabilitation, with the benefits associated using a program tailored to their needs and outcome goals.
The bottom line
Early management of stroke involves first determining whether someone is a candidate for reperfusion therapy with alteplase or thrombectomy and then, if not, admitting them to a monitored setting to screen for atrial fibrillation and evaluation for carotid stenosis. Patients should be evaluated for both depression and swallowing function, and there should be initiation of deep vein thrombosis prevention, appropriate management of elevated blood pressures, anti-platelet therapy, and statin therapy as well as plans for rehabilitation services.
Reference
Powers WJ et al. on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Callahan is an attending physician and preceptor in the family medicine residency program at Abington Jefferson Health.
(AIS). Conceptually, early management can be separated into initial triage and decisions about intervention to restore blood flow with thrombolysis or mechanical thrombectomy. If reperfusion therapy is not appropriate, then the focus is on management to minimize further damage from the stroke, decrease the likelihood of recurrence, and lessen secondary problems related to the stroke.
All patients with AIS should receive noncontrast CT to determine if there is evidence of a hemorrhagic stroke and, if such evidence exists, than the patient is not a candidate for thrombolysis. Intravenous alteplase should be considered for patients who present within 3 hours of stroke onset and for selected patients presenting between 3-4.5 hours after stroke onset (for more details, see Table 6 in the guidelines). Selected patients with AIS who present within 6-24 hours of last time they were known to be normal and who have large vessel occlusion in the anterior circulation, may be candidates for mechanical thrombectomy in specialized centers. Patients who are not candidates for acute interventions should then be managed according to early stroke management guidelines.
Early stroke management for patients with AIS admitted to medical floors involves attention to blood pressure, glucose, and antiplatelet therapy. For patients with blood pressure lower than 220/120 mm Hg who did not receive IV alteplase or thrombectomy, treatment of hypertension in the first 48-72 hours after an AIS does not change the outcome. It is reasonable when patients have BP greater than or equal to 220/120 mm Hg, to lower blood pressure by 15% during the first 24 hours after onset of stroke. Starting or restarting antihypertensive therapy during hospitalization in patients with blood pressure higher than 140/90 mm Hg who are neurologically stable improves long-term blood pressure control and is considered a reasonable strategy.
For patients with noncardioembolic AIS, the use of antiplatelet agents rather than oral anticoagulation is recommended. Patients should be treated with aspirin 160 mg-325 mg within 24-48 hours of presentation. In patients unsafe or unable to swallow, rectal or nasogastric administration is recommended. In patients with minor stroke, 21 days of dual-antiplatelet therapy (aspirin and clopidogrel) started within 24 hours can decrease stroke recurrence for the first 90 days after a stroke. This recommendation is based on a single study, the CHANCE trial, in a homogeneous population in China, and its generalizability is not known. If a patient had an AIS while already on aspirin, there is some evidence supporting a decreased risk of major cardiovascular events and recurrent stroke in patients switching to an alternative antiplatelet agent or combination antiplatelet therapy. Because of methodologic issues in the those studies, the guideline concludes that, for those already on aspirin, it is of unclear benefit to increase the dose of aspirin, switch to a different antiplatelet agent, or add a second antiplatelet agent. Switching to warfarin is not beneficial for secondary stroke prevention. High-dose statin therapy should be initiated. For patients with AIS in the setting of atrial fibrillation, oral anticoagulation can be started within 4-14 days after the stroke. One study showed that anticoagulation should not be started before 4 days after the stroke, with a hazard ratio of 0.53 for starting anticoagulation at 4-14 days, compared with less than 4 days.
Hyperglycemia should be controlled to a range of 140-180 mg/dL, because higher values are associated with worse outcomes. Oxygen should be used if needed to maintain oxygen saturation greater than 94%. High-intensity statin therapy should be used, and smoking cessation is strongly encouraged for those who use tobacco, with avoidance of secondhand smoke whenever possible.
Patients should be screened for dysphagia before taking anything per oral, including medications. A nasogastric tube may be considered within the first 7 days, if patients are dysphagic. Oral hygiene protocols may include antibacterial mouth rinse, systematic oral care, and decontamination gel to decrease the risk of pneumonia .
For deep vein thrombosis prophylaxis, intermittent pneumatic compression, in addition to the aspirin that a patient is on is reasonable, and the benefit of prophylactic-dose subcutaneous heparin (unfractionated heparin or low-molecular-weight heparin) in immobile patients with AIS is not well established.
In the poststroke setting, patients should be screened for depression and, if appropriate, treated with antidepressants. Regular skin assessments are recommended with objective scales, and skin friction and pressure should be actively minimized with regular turning, good skin hygiene, and use of specialized mattresses, wheelchair cushions, and seating until mobility returns. Early rehabilitation for hospitalized stroke patients should be provided, but high-dose, very-early mobilization within 24 hours of stroke should not be done because it reduces the odds of a favorable outcome at 3 months.
Completing the diagnostic evaluation for the cause of stroke and decreasing the chance of future strokes should be part of the initial hospitalization. While MRI is more sensitive than is CT for detecting AIS, routine use of MRI in all patients with AIS is not cost effective and therefore is not recommended. For patients with nondisabling AIS in the carotid territory and who are candidates for carotid endarterectomy or stenting, noninvasive imaging of the cervical vessels should be performed within 24 hours of admission, with plans for carotid revascularization between 48 hours and 7 days if indicated. Cardiac monitoring for at least the first 24 hours of admission should be performed, while primarily looking for atrial fibrillation as a cause of stroke. In some patients, prolonged cardiac monitoring may be reasonable. With prolonged cardiac monitoring, atrial fibrillation is newly detected in nearly a quarter of patients with stroke or TIA, but the effect on outcomes is uncertain. Routine use of echocardiography is not recommended but may be done in selected patients. All patients should be screened for diabetes. It is not clear whether screening for thrombophilic states is useful.
All patients should be counseled on stroke, and provided education about it and how it will affect their lives. Following their acute medical stay, all patients will benefit from rehabilitation, with the benefits associated using a program tailored to their needs and outcome goals.
The bottom line
Early management of stroke involves first determining whether someone is a candidate for reperfusion therapy with alteplase or thrombectomy and then, if not, admitting them to a monitored setting to screen for atrial fibrillation and evaluation for carotid stenosis. Patients should be evaluated for both depression and swallowing function, and there should be initiation of deep vein thrombosis prevention, appropriate management of elevated blood pressures, anti-platelet therapy, and statin therapy as well as plans for rehabilitation services.
Reference
Powers WJ et al. on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Callahan is an attending physician and preceptor in the family medicine residency program at Abington Jefferson Health.
(AIS). Conceptually, early management can be separated into initial triage and decisions about intervention to restore blood flow with thrombolysis or mechanical thrombectomy. If reperfusion therapy is not appropriate, then the focus is on management to minimize further damage from the stroke, decrease the likelihood of recurrence, and lessen secondary problems related to the stroke.
All patients with AIS should receive noncontrast CT to determine if there is evidence of a hemorrhagic stroke and, if such evidence exists, than the patient is not a candidate for thrombolysis. Intravenous alteplase should be considered for patients who present within 3 hours of stroke onset and for selected patients presenting between 3-4.5 hours after stroke onset (for more details, see Table 6 in the guidelines). Selected patients with AIS who present within 6-24 hours of last time they were known to be normal and who have large vessel occlusion in the anterior circulation, may be candidates for mechanical thrombectomy in specialized centers. Patients who are not candidates for acute interventions should then be managed according to early stroke management guidelines.
Early stroke management for patients with AIS admitted to medical floors involves attention to blood pressure, glucose, and antiplatelet therapy. For patients with blood pressure lower than 220/120 mm Hg who did not receive IV alteplase or thrombectomy, treatment of hypertension in the first 48-72 hours after an AIS does not change the outcome. It is reasonable when patients have BP greater than or equal to 220/120 mm Hg, to lower blood pressure by 15% during the first 24 hours after onset of stroke. Starting or restarting antihypertensive therapy during hospitalization in patients with blood pressure higher than 140/90 mm Hg who are neurologically stable improves long-term blood pressure control and is considered a reasonable strategy.
For patients with noncardioembolic AIS, the use of antiplatelet agents rather than oral anticoagulation is recommended. Patients should be treated with aspirin 160 mg-325 mg within 24-48 hours of presentation. In patients unsafe or unable to swallow, rectal or nasogastric administration is recommended. In patients with minor stroke, 21 days of dual-antiplatelet therapy (aspirin and clopidogrel) started within 24 hours can decrease stroke recurrence for the first 90 days after a stroke. This recommendation is based on a single study, the CHANCE trial, in a homogeneous population in China, and its generalizability is not known. If a patient had an AIS while already on aspirin, there is some evidence supporting a decreased risk of major cardiovascular events and recurrent stroke in patients switching to an alternative antiplatelet agent or combination antiplatelet therapy. Because of methodologic issues in the those studies, the guideline concludes that, for those already on aspirin, it is of unclear benefit to increase the dose of aspirin, switch to a different antiplatelet agent, or add a second antiplatelet agent. Switching to warfarin is not beneficial for secondary stroke prevention. High-dose statin therapy should be initiated. For patients with AIS in the setting of atrial fibrillation, oral anticoagulation can be started within 4-14 days after the stroke. One study showed that anticoagulation should not be started before 4 days after the stroke, with a hazard ratio of 0.53 for starting anticoagulation at 4-14 days, compared with less than 4 days.
Hyperglycemia should be controlled to a range of 140-180 mg/dL, because higher values are associated with worse outcomes. Oxygen should be used if needed to maintain oxygen saturation greater than 94%. High-intensity statin therapy should be used, and smoking cessation is strongly encouraged for those who use tobacco, with avoidance of secondhand smoke whenever possible.
Patients should be screened for dysphagia before taking anything per oral, including medications. A nasogastric tube may be considered within the first 7 days, if patients are dysphagic. Oral hygiene protocols may include antibacterial mouth rinse, systematic oral care, and decontamination gel to decrease the risk of pneumonia .
For deep vein thrombosis prophylaxis, intermittent pneumatic compression, in addition to the aspirin that a patient is on is reasonable, and the benefit of prophylactic-dose subcutaneous heparin (unfractionated heparin or low-molecular-weight heparin) in immobile patients with AIS is not well established.
In the poststroke setting, patients should be screened for depression and, if appropriate, treated with antidepressants. Regular skin assessments are recommended with objective scales, and skin friction and pressure should be actively minimized with regular turning, good skin hygiene, and use of specialized mattresses, wheelchair cushions, and seating until mobility returns. Early rehabilitation for hospitalized stroke patients should be provided, but high-dose, very-early mobilization within 24 hours of stroke should not be done because it reduces the odds of a favorable outcome at 3 months.
Completing the diagnostic evaluation for the cause of stroke and decreasing the chance of future strokes should be part of the initial hospitalization. While MRI is more sensitive than is CT for detecting AIS, routine use of MRI in all patients with AIS is not cost effective and therefore is not recommended. For patients with nondisabling AIS in the carotid territory and who are candidates for carotid endarterectomy or stenting, noninvasive imaging of the cervical vessels should be performed within 24 hours of admission, with plans for carotid revascularization between 48 hours and 7 days if indicated. Cardiac monitoring for at least the first 24 hours of admission should be performed, while primarily looking for atrial fibrillation as a cause of stroke. In some patients, prolonged cardiac monitoring may be reasonable. With prolonged cardiac monitoring, atrial fibrillation is newly detected in nearly a quarter of patients with stroke or TIA, but the effect on outcomes is uncertain. Routine use of echocardiography is not recommended but may be done in selected patients. All patients should be screened for diabetes. It is not clear whether screening for thrombophilic states is useful.
All patients should be counseled on stroke, and provided education about it and how it will affect their lives. Following their acute medical stay, all patients will benefit from rehabilitation, with the benefits associated using a program tailored to their needs and outcome goals.
The bottom line
Early management of stroke involves first determining whether someone is a candidate for reperfusion therapy with alteplase or thrombectomy and then, if not, admitting them to a monitored setting to screen for atrial fibrillation and evaluation for carotid stenosis. Patients should be evaluated for both depression and swallowing function, and there should be initiation of deep vein thrombosis prevention, appropriate management of elevated blood pressures, anti-platelet therapy, and statin therapy as well as plans for rehabilitation services.
Reference
Powers WJ et al. on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Callahan is an attending physician and preceptor in the family medicine residency program at Abington Jefferson Health.
2013 IDSA clinical practice guideline for vaccination of the immunocompromised host
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
Diagnosis and management of celiac disease
Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.
In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.
Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.
Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.
In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.
The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:
• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.
• Those with symptoms suggestive of celiac disease.
• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.
The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.
If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.
Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.
The Bottom Line
Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.
Reference
Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the family medicine residency program at Abington.
Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.
In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.
Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.
Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.
In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.
The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:
• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.
• Those with symptoms suggestive of celiac disease.
• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.
The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.
If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.
Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.
The Bottom Line
Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.
Reference
Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the family medicine residency program at Abington.
Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.
In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.
Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.
Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.
In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.
The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:
• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.
• Those with symptoms suggestive of celiac disease.
• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.
The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.
If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.
Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.
The Bottom Line
Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.
Reference
Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the family medicine residency program at Abington.
