Coeliac disease

Prescribing Notes:

• Gluten-free foods should only be prescribed on NHS prescriptions for patients with established gluten-sensitive enteropathies, coeliac disease and dermatitis herpetiformis.
• In adults diagnosis must be made by positive antibody blood test and/or gut biopsy. Initial diagnosis and management should involve a gastroenterologist and a dietitian.
• In paediatrics (young people under 16 years old), diagnosis and management must be made by a specialist paediatric dietitian and/or consultant paediatric gastroenterologist. Guidance on the current and new ESPGHAN diagnosis and management of coeliac disease can be found on the paediatric gastroenterology pages on RefHelp. If there are any questions, please contact the respective coeliac services in NHS Borders, NHS Fife or NHS Lothian.
• Prescriptions for gluten-free foods should not be issued until diagnosis has been confirmed (even a short period of gluten avoidance will mask the diagnosis).
• Only those foods listed by the Advisory Committee on Borderline Substances (ACBS) should be prescribed.
• The Scottish Government Gluten-Free Food (GFF) Pharmaceutical Service allows patients to self-manage their gluten free prescriptions with the assistance of community pharmacy. Further information on the Gluten-Free Food (GFF) Service can be found on NHS Inform.

Quantities to Prescribe

• The quantity of gluten-free foods a patient requires is based on recommended nutritional intake for a healthy balanced diet, following these key principles:
  
  • total carbohydrate intake should provide 50% of a patient’s total energy requirement. This should come from potatoes and rice, as well as gluten-free products;
  • gluten-free foods should provide 15% of a patient’s total energy requirements.
• Coeliac UK provide guidance on the number of units that may be required by a patient. This may need to be increased for adults with particularly active lifestyles or occupations; or for children and young people with particularly active lifestyles or those who require additional nutrition for growth. Exceptions to these amounts should be on advice of a dietitian.
• Gluten-free foods that are not normally required are biscuits, cakes and cake mixes. However, exemptions may be made for those children and young people with growth concerns - if so, this will be advised in writing by specific recommendation of a paediatric dietitian.

• Gluten-free foods promote compliance to a gluten-free diet. They provide nutrients that may not be readily available from other sources e.g. calcium and also support self-management.
• Some individuals with coeliac disease may require to avoid additional foods as well as gluten. It is important to check for additional allergies or intolerances (i.e. secondary lactose intolerance) or an unrelated allergy.
• Dietitians may recommend other products on the ACBS list on the basis of nutritional need or where growth problems are identified, the reasons for this should be documented.
• Some companies charge pharmacies for delivery of these products. This has been taken into account in the development of the formulary. Prescribers should be aware that any non-formulary prescribing may incur delivery costs (i.e. prescribing costs) in excess of the individual cost of the product.
• Barkat xanthan gum can be prescribed for patients that do home baking. Delivery costs are incurred with this product.