Guideline for the prescribing of gluten-free
products within primary care
on NHS prescriptions
CONTENTS
1 INTRODUCTION
1.1 Background
1.2 Purpose
1.3 Scope
3
3
3
3
2 DUTIES
4
3 PROCEDURE/COURSE OF ACTION REQUIRED
3.1 Presentation to Prescription – The Patient Process
3.1.1 Adults
3.1.2 Children and adolescents (< 16 years of age)
3.2 Prescribing of Gluten-Free Foods on NHS prescriptions
3.3 Quantities of Gluten-Free Foods to be prescribed
4
4
5
5
6
6
4 IMPLEMENTATION
4.1 Training and awareness
4.2 Audit and monitoring
4.3 Information for Patients
8
8
8
8
5 REFERENCES
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1 INTRODUCTION
1.1 Background
NHS North Staffordshire has a legal responsibility to provide comprehensive, effective and accessible
health services to its population within a finite resource, which includes the provision of prescribed foods for
patients who require special diets.
Coeliac disease is a common life-long condition with a prevalence of about 1% in Europe (Coeliac UK,
2004). The cornerstone of treatment is a gluten-free diet and patients require regular support from a
registered dietician.

‘Coeliac disease is an inflammatory condition of the small intestinal mucosa that is induced by the
ingestion of gluten and which improves clinically and histologically when gluten is excluded from the
diet’ (British Society of Gastroenterology, 2010)

In untreated coeliac disease, damage to the surface of the small intestine results in reduced ability
to digest and absorb food and causes malabsorption of essential nutrients such as iron, folic acid
and calcium. This can lead to a variety of health problems including diarrhoea, anaemia, reduced
appetite, weight loss, mouth ulcers, abdominal bloating / distension and faltering growth in
childhood (Coeliac UK, 2004).

Coeliac disease is unique among gastrointestinal disorders in the availability of an effective dietary
treatment that will restore almost all patients to full health, and help to protect against the
development of complications (Coeliac UK, 2004).

Coeliac disease requires life-long exclusion of gluten from the diet and dietary compliance is
essential to successful management. However, some patients with coeliac disease may require
with other dietary exclusions in addition to gluten-free, e.g. wheat and lactose. Any other medical
conditions, e.g. diabetes and osteoporosis, should also be taken into account.
During the period of 2010-2011, North Staffordshire spent just over £130,000 on gluten-free products, this
represents an increase of 22% from 2009-2010.
1.2 Purpose
The purpose of this Guideline is to support the standardisation of prescribing of gluten-free foods in primary
care ensuring best practice and consistency across all GP practices.
The Guideline will apply to the following groups of patients:

People with coeliac disease requiring only gluten-free foods
Individual authorised prescribers will continue to be legally responsible for their decisions and any
consequences.
1.3 Scope
All GP practices in the North Staffordshire area are expected to incorporate this Guideline into their
practice procedures and the Medicines Management Team will monitor practice performance in line with
this Guideline on a quarterly basis. GP practices are expected to review their prescribing to keep within this
Guideline.
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2 DUTIES
The Medicines Management Team is responsible for supporting the implementation of this Guideline
across North Staffordshire.
3 PROCEDURE / COURSE OF ACTION
3.1 Presentation to Prescription – The Patient Process
Patients with a diagnosis of coeliac disease will be managed by a multi-disciplinary team across both
primary and secondary care including GP, practice nurse, gastroenterologist / paediatric gastroenterologist,
registered dietician (adult / paediatrics) and pharmacist.

All patients receiving prescriptions for gluten-free foods should have had a CONFIRMED diagnosis
from a Gastroenterologist / Paediatric Gastroenterologist - see tables 3.1.1 and 3.1.2

Any gluten-free foods being prescribed for patients without a confirmed diagnosis should be
stopped.
People with coeliac disease should avoid all foods containing gluten, a protein found in wheat, rye and
barley. NB Sensitivity to oats varies between individual adults – advice on inclusion or exclusion should be
sought from the patient’s registered dietician; oats should always be excluded from the diets of children
diagnosed with coeliac disease.
A gluten-free diet requires the avoidance of any food made from ingredients containing gluten such as
bread, flour, pasta, cakes, pastries and biscuits. There are many other foods including ready meals and
manufactured meat products such as sausages which can often contain gluten, e.g. cereals used as fillers.
People with coeliac disease obtain gluten-free foods from a variety of sources including GP (FP10
prescription), supermarket, health food shop, pharmacy and mail order / telephone / internet.
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3.1.1 Adults with Coeliac Disease
Reference – Coeliac UK (2004), Gluten-free foods: a prescribing guide
3.1.2 Children and adolescents (< 16 years of age)
Reference – Coeliac UK (2004), Gluten-free foods: a prescribing guide
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3.2 Prescribing of Gluten-Free Foods on NHS Prescriptions
The range of products available for prescribing nationally is listed in Part XV of the Drug Tariff (Borderline
Substances).

These include a variety of gluten-free bread / rolls, crackers and crispbreads, flour / flour-type
mixes, pasta, pizza base (staple food replacements).

Other gluten-free products such as biscuits, cereals, cakes/cake mixes, luxury breads and
ready meals are also available from all supermarkets and patients should purchase these if
required– they should no longer be prescribed on FP10. NB These products are widely
available in shops and are not considered essential to the diet; they are also contrary to NHS
recommendations for eating for health.
NB Registered dieticians may, on occasions, request additional prescribable gluten-free ‘staple’ foods and /
or gluten-free foods that fall outside the agreed ‘staple food’ list. This will be based on a full and detailed
dietary assessment of an individual patient’s specific clinical needs, e.g. underweight adult or child
requiring additional energy / nutrients. The registered dietician will be responsible for regularly reviewing
the patient and advising their GP of any ongoing need for these additional gluten-free foods.
It is good practice for patients to try a gluten-free food first before receiving a full month’s prescription;
some manufacturers also offer sample packs.
It can be difficult to estimate appropriate quantities of gluten-free foods to prescribe on repeat prescription
– the following guidance will assist with this; it is also useful to ask the patient about quantities of gluten
containing ‘staple’ foods (eg: bread, pasta, flour) eaten per month before they started experiencing
symptoms. Also consider the patient’s skills and facilities for cooking. NB A gluten-free loaf is a different
size to an ‘ordinary’ loaf of bread – remember to adjust for this when working out quantities to prescribe.
Having agreed on a list of products, it is important to provide patients with flexibility to change items.

A person’s need for food often changes over time, and they may wish to try new items – it is
recommended to switch like for like products on their repeat medication list.

Large quantities of gluten-free foods should not be prescribed as many products are difficult to store
and expiry dates vary causing excessive wastage.
Prescribing should be for a maximum of ONE MONTH at a time.
3.3 Quantities to be prescribed
The following tables provide guidance on the monthly amount of prescribable gluten-free food, calculated in
units based on energy and nutrient requirements of different age groups and genders. Additional amounts
have been added for high levels of physical activity, breastfeeding and the third trimester of pregnancy.
This guidance is based on:

National nutritional recommendations and make assumptions that in addition to gluten-free food on
prescription individuals eat naturally gluten-free carbohydrate food such as rice and potatoes

Consumption data from the National Diet and Nutrition Surveys (Office for National Statistics and
Medical Research Council Human Nutrition Research, 2002) and from individual records of NHS
patients with coeliac disease

The eat well plate (Food Standards Agency, 2007) where carbohydrates should provide 50% of
total energy.
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Age group
Child
1-3 years
4-6 years
7-10 years
11-14 years
15-18 years
19-59 years
60-74 years
75+ years
19-74 years
75+ years
Male
Female
Breastfeeding
3rd trimester
High physical
activity level
Maximum
number of
units of
gluten- free
foods per
month
10
11
13
15
18
18
16
14
14
12
Add 4 units
Add 1 unit
Add 4 units
The number of units represented by the prescribable item
is as follows:
Item
400g loaf
400g rolls / baguettes
500g bread mix/ flour
200g crackers / crispbreads
500g pasta
2 x 110-180g pizza base
Number of units
1
1
2
1
2
2
References:
Coeliac UK (January 2011)
British Dietetic Association (BDA), Primary Care Society for Gastroenterology (PCSG), Coeliac UK (2004)
Some patients may be receiving in excess of this guidance and some people may be receiving less. The
unit recommendations are based on national nutritional recommendations and the amount of products
prescribed should follow this guidance and should only be exceeded in exceptional circumstances, based
on the advise of a registered dietitian (adult / paediatric) or the patient’s doctor / Gastroenterologist /
Pediatrician or Paediatric Gastroenterologist.
NB Registered dieticians may, on occasions, request additional prescribable gluten-free ‘staple’ foods and /
or gluten-free foods that fall outside the agreed ‘staple food’ list. This will be based on a full and detailed
dietary assessment of an individual patient’s specific clinical needs, e.g. underweight adult or child
requiring additional energy / nutrients. The registered dietician will be responsible for regularly reviewing
the patient and advising their GP of any ongoing need for these additional gluten-free foods.
Example: Elderly female aged 75 years:

On questioning, the patient is sedentary, eating a well balanced diet and normal weight (Body Mass
Index 20). Enjoys most foods but dislikes pasta, and has a good appetite in general.

Suggested prescription = 12 units of gluten-free foods per month
6 x 400g loaves of bread = 6 units
2 x 400g rolls = 2 units
2 x200g crackers = 2 units
1 x 200g crispbreads = 1unit
1 x 400g baguette = 1 unit
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Clinician’s should use their discretion in cases where nutritional intake is at risk. There may be cases
where crackers should be prescribed instead of bread, for example, for older patients with dental problems
or biscuits are recommended for individuals who are underweight or additional units are recommended in
patients with additional calorie requirements. A registered dietitian is best placed to assess individual
requirements. (Coeliac UK, January 2011)
4 IMPLEMENTATION
Successful implementation of this Guideline requires a clear understanding and communication across our
primary care setting. Successful in this context means that the appropriate gluten-free ‘staple’ foods are
prescribed within the recommended unit allocation for each confirmed diagnosed of coeliac disease.
4.1 Training and awareness
Healthcare professionals can be supported to understand and apply the principles of this Guideline by the
Medicines Management Team. The Guideline should also be introduced to all practice staff at their local
practice meetings.
4.2 Audit and monitoring
The Medicines Management Team will need to ensure that audit strategies are in place in order for the
CCG to be assured that this Guideline is being followed appropriately.
Practices, supported by the Medicines Management Team, will undertake an initial audit to highlight
patients whose current medication does not fit within this Guideline. A list of recommendations will then be
given to each practice along with any other findings found within the audit. The team will then monitor
concordance by looking at quarterly prescribing habits.
4.3 Information for Patients
Information to any patients affected by this Guideline will be disseminated via letters to their home address;
included in this will also be a contact number for a member of the Medicines Management Team. Patients
will be encouraged to call with any queries or questions that they may have regarding changes to their
gluten-free foods.
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5 REFERENCES
British Society of Gastroenterology (2010) The Management of adults with coeliac disease.
http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease-2010.html
Coeliac UK, January 2011. Prescribing of gluten-free foods: Coeliac UK’s position.
http://www.coeliac.org.uk/healthcare-professionals/healthcare-professional-newsletters/january-2011professional-exg/prescribi
British Dietetic Association (BDA), Primary Care Society for Gastroenterology (PCSG), Coeliac UK (2004).
Gluten-free foods: A Prescribing Guide.
Office for National Statistics and Medical Research Council Human Nutrition Research (2002). The
National Diet & Nutrition Survey: adults aged 19 to 64 years (2002) Types and quantities of foods
consumed. A survey carried out in Great Britain on behalf of the Food Standards Agency and the
Department of Health.
Food Standards Agency (2007). Eat Well Plate.
The Guideline has been developed with professional guidance from the Strategic Professional Lead –
Dietetics, South Staffordshire PCT (Provider Services)
This Guideline was adapted from South Staffordshire Primary Care Trust.
.
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