The European Society for the Study of Coeliac Disease (ESsCD) has published the second part of its updated 2025 guidelines on coeliac disease in adults, focusing on management and follow-up.

Following the first instalment dedicated to diagnosis (which we discussed here), this document addresses the most significant clinical challenges in daily practice: from the safe inclusion of oats and the use of the low-FODMAP diet, to the management of exocrine pancreatic insufficiency and bone health. It also covers psychosocial support, digital care models, the paediatric-to-adult transition, and updated therapeutic strategies for refractory coeliac disease, including new pharmacological options.

In this article, we analyse the key points of the new recommendations to support clinicians in the optimal management of adult coeliac patients.

The gluten-free diet (GFD) remains the fundamental and indispensable treatment for coeliac disease. The 2025 guidelines establish the following key principles:

• The safety threshold is no more than 10 mg of gluten per day
• Only certified gluten-free oats are safe and may be introduced from the time of diagnosis as part of a balanced diet
• A small proportion of patients may develop specific intolerance to avenin

For patients with persistent gastrointestinal symptoms despite the GFD and confirmed histological healing, the guidelines introduce the low-FODMAP diet as an additional approach, to be considered only after ruling out other causes and under the supervision of an experienced dietitian.

The ESsCD 2025 guidelines recommend long-term follow-up for all adult coeliac patients, with the aim of monitoring dietary adherence, detecting complications and comorbidities, and ensuring ongoing nutritional and psychosocial support. The choice between a fixed-interval model and an individualised one is left to clinical judgement, based on factors such as adherence, symptoms and serological response.

For monitoring, anti-TG2 IgA serology remains the primary tool for identifying ongoing gluten exposure, albeit with its limitations: a negative result, in fact, does not guarantee either strict dietary adherence or histological healing.

A follow-up duodenal biopsy is not routinely recommended, but should be considered on a case-by-case basis in the presence of persistent or worsening symptoms, diagnosis in individuals over 45 years of age, or an initially severe presentation.

The 2025 ESsCD guidelines mark a significant evolution in the management of coeliac disease in adults, shifting the focus from gluten exclusion alone towards a personalised, proactive and multidisciplinary care model. For clinicians, the practical message is clear: monitoring is not enough; we must anticipate nutritional deficiencies, comorbidities, psychosocial distress and long-term complications.

The availability of new diagnostic tools, structured follow-up pathways and updated treatment options for refractory disease now provides a solid foundation for tangibly improving outcomes and quality of life for adult coeliac patients.