Response

Consider this scenario: The brother of one of your patients with type 1 diabetes checks his blood sugar level on the home glucometer and finds it to be 17.5 mmol/L. Would you send this patient urgently to the local laboratory for confirmation of hyperglycemia or accept the diagnosis based on the glucometer test alone? Even if the concordance between home glucometer and laboratory measure were perfect, would you not do a laboratory blood glucose measurement to confirm the diagnosis of a serious, lifelong disorder? Celiac disease should be treated no differently.

Laboratory serologic testing for celiac disease is currently funded by the provincial health care programs in all provinces except Ontario (and is available in Ontario without cost in most academic health institutions). Efforts are being made to make this universally available in that province as well. As the tests become widely available, there is little delay in getting the results back. I agree that the availability of timely upper gastrointestinal endoscopy is a problem in Canada. This should be addressed. But the answer is not to start treating individuals who have positive home blood test results for celiac disease with gluten-free diets. We expressed reservations in our article that such self-diagnosis can have serious implications, including lack of both proper medical evaluation for nutritional efficiencies and adequate counseling from a registered dietitian with expertise in gluten-free diet regimens.1 It must be remembered that celiac disease is a permanent sensitivity to gluten and the treatment consists of a lifelong, strict adherence to a gluten-free diet. The cost of making a definite diagnosis would likely be less than that of unconfirmed diagnosis, as the patients in the latter group will continue to access health care services.

In Canada, home blood testing for celiac disease is uncharted territory. One needs to see how this plays out over time. The medical profession should continue to advocate even better availability of laboratory serologic screening tests and timely access to endoscopy for confirmation of diagnosis.

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