**Background:** Celiac disease (CeD) is an immune-mediated enteropathy triggered by gluten, affecting approximately 1% of the population. Lifelong adherence to a gluten-free diet (GFD) is mandatory, not voluntary. Despite this, follow-up (FU) care for CeD patients is inconsistent, inadequate, or absent for many. Up to 75% of patients diagnosed in childhood do not receive proper transition to adult follow-up. The authors note that research has focused heavily on diagnosis and pathophysiology, leaving a gap in evidence-based FU models. Persistent symptoms and mucosal changes occur in 20% to 40% of adult CeD patients, underscoring the need for structured FU.
**Methods:** This is a narrative review synthesizing expert opinion and available literature on CeD follow-up. The authors discuss key FU components including disease monitoring intervals, dietary adherence assessment, indications for follow-up biopsy, screening of family members, multidisciplinary team composition, and emerging care models such as telemedicine and virtual clinics. They reference existing guidelines from the European Society for the Study of Celiac Disease (ESsCD) and the American College of Gastroenterology (ACG).
**Key Results:** The review identifies several critical findings from the literature: (1) IgA anti-TG2 antibodies have poor sensitivity for predicting persistent mucosal architectural distortion, and negative antibodies do not rule out ongoing villous atrophy. (2) About 40% of patients re-biopsied at 12 months still have villous atrophy despite good dietary compliance. (3) First-degree relatives have a pooled CeD prevalence of 7.5%, with sisters and daughters at highest risk (1 in 7 and 1 in 8, respectively). (4) Adherence to GFD varies between 42% and 91% depending on the population studied. (5) 25–40% of patients receive no dietetic input and are often lost to follow-up in primary care. (6) HLA-DQ2.5, HLA-DQ2.2, and HLA-DQ8 are found in almost 99% of CeD patients versus 20–40% of controls. The authors propose a suggested FU scheme (Table 1) and emphasize that stable patients should be evaluated every 12–24 months, with FU by general practitioners considered in specific situations. They highlight the need for a "Red Flags" index for refractory CeD (RCD), which carries higher risk of lymphoproliferative malignancies, and recommend that RCD type II patients be referred to specialized secondary centers.
**Clinical Implications:** The authors conclude that comprehensive CeD management requires a strategic, multidisciplinary approach with dedicated teams including gastroenterologists, specialized dietitians, psychologists, and, when needed, dermatologists, rheumatologists, and hepatologists. They note that 80–90% of patients on GFD notice symptom improvement within weeks to months, but small bowel healing may take years. Key recommendations include: checking IgA-TG2 antibodies every six months until normalization; performing follow-up biopsy in adults with severe initial presentation (especially >40 years) after 1–2 years of GFD; screening symptomatic first-degree relatives (with HLA typing as a once-only test); ensuring pneumococcal vaccination; monitoring for metabolic syndrome and fatty liver disease; and providing psychosocial support. The authors stress that there is a paucity of data on optimal clinic visit intervals, cost-effectiveness, and quality indicators. They advocate for development of validated patient-reported outcome tools (e.g., a CeD-Monitoring Index), expanded use of telemedicine and smartphone applications, and establishment of formal CeD patient registries. They note that general practitioners could play a key role in FU if a critical number of CeD patients per GP is reached, as seen in Finland, but caution that most GPs currently lack sufficient CeD expertise.