Article Text

Clinical characteristics, hospitalisation and mortality rates of COVID-19 among patients with coeliac disease in the USA: a multicentre network study
  1. Emad Mansoor1,
  2. Muhammed Mustafa Alikhan2,
  3. Jaime Abraham Perez3,
  4. Kayla Schlick3,
  5. Mohannad Abou Saleh4,
  6. Alberto Rubio-Tapia4
  1. 1 Department of Medicine; Digestive Health Institute, University Hospitals of Cleveland, Cleveland, Ohio, USA
  2. 2 Department of Medicine, University Hospitals of Cleveland, Cleveland, Ohio, USA
  3. 3 Center for Clinical Research, Case Western Reserve University, Cleveland, Ohio, USA
  4. 4 Department of Medicine; Division of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr Alberto Rubio-Tapia, Cleveland Clinic, Cleveland, Ohio, USA; rubiota{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

We read with interest the work by Belli et al 1 regarding outcomes of COVID-19 in liver transplant candidates. The authors concluded that liver transplant candidates were at risk of early death, especially those with decompensated cirrhosis and model for end-stage liver disease score≥15.

Similarly, patients with coeliac disease (CD) are a population of interest in regards to clinical outcomes after a diagnosis of COVID-19. Although the evidence of an impact of other chronic disorders on the outcome of COVID-19 is emerging, the consequences of COVID-19 infection in individuals with CD remain uncertain.2–4 We sought to define the rates of hospitalisation, mortality, thrombosis or intensive care unit (ICU) requirement in individuals with CD and COVID-19.

We used a large healthcare research network (TriNetX) to compile the electronic medical records of adult patients (age ≥18 years) with CD and confirmed COVID-19 infection (CD cohort) from 51 healthcare organisations in the USA, between 1 January 2020 and 7 July 2021. Within this same time period, we also identified COVID-19 positive patients with no history of CD (non-CD cohort). The definition of CD required an International Classification of Disease, 10th Revision (ICD-10) diagnostic code and additional codes related to CD diagnosis such as villous atrophy present on biopsy of small intestine and positive autoantibody screening for CD. For both cohorts, we studied the risk of hospitalisation (defined as a composite outcome of inpatient or critical care services), mortality, thrombosis (defined as a composite outcome of deep vein thrombosis, acute pulmonary embolism, stroke or myocardial infarction) and ICU requirement (requiring mechanical ventilation or extracorporeal membrane oxygenation) within 90 days of COVID-19 diagnosis. We performed 1:1 propensity score matching (PSM) using a greedy nearest-neighbour matching algorithm to account for potential confounding variables (online supplemental file 1).

Supplemental material

For each outcome, we estimated ORs and 95% CI to compare the risk of hospitalisation, mortality, thrombosis and ICU requirement between the CD cohort and the non-CD cohort. We identified a total of 810 972 non-CD patients with COVID-19 and 599 CD patients with COVID-19. The CD and non-CD cohorts were relatively balanced after PSM (n=598 each group). Overall, there were no significant differences among any of the measured outcomes between CD and non-CD patients with COVID-19 after PSM (table 1). Before PSM, 18.20% of patients in the CD cohort were hospitalised compared with 11.34% in the non-CD cohort (OR 1.74; 95% CI 1.41 to 2.14; p<0.0001). However, after PSM, this association became insignificant (OR 0.96; 95% CI 0.71 to 1.11; p=0.0906). Similarly, 5.34% of patients in the CD cohort developed thrombosis compared with 2.06% in the non-CD cohort before matching (OR 2.69; 95% CI 1.88 to 3.83; p<0.0001). However, after PSM, this difference became insignificant (OR 0.938; 95% CI 0.57 to 1.54; p=0.800).

Table 1

Differences in outcomes between non-coeliac disease (non-CD) patients with COVID-19 and coeliac disease (CD) patients with COVID-19 after having performed analysis with stricter criteria for CD case

This is the largest study characterising CD patients with COVID-19 to date to systematically investigate outcomes of CD patients with COVID-19. Our findings are consistent with a recent population-based study from Sweden, similarly demonstrating no significant increase in risk of hospitalisation, severe COVID-19 or increase in mortality between CD and non-CD patients afflicted with COVID-19.5 One limitation of our study is that the diagnosis of CD is based on a diagnostic ICD-10 code but likely mitigated by the requirement of additional codes related to CD.

In conclusion, we found that CD patients infected with COVID-19 do not carry a significantly higher risk of hospitalisation, mortality, thrombosis or ICU care requirement compared with COVID-19 patients without CD following propensity score matching. Although reassuring, this study is all about outcomes in individuals with diagnosed CD and the potential impact of COVID-19 in patients with undiagnosed CD remains unknown.

Ethics statements

Patient consent for publication


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • EM and MMA are joint first authors.

  • Twitter @MMAlikhanMD

  • EM and MMA contributed equally.

  • Contributors Study conception and design: EM, MAS and AR-T. Acquisition of data: JAP, KS, EM, MAS and AR-T. Analysis and Interpretation: JAP, KS, MMA, EM, MAS and AR-T. Drafting of manuscript: MMA, EM, MAS and AR-T. Critical revision: MMA, EM, MAS and AR-T. Statistical analysis: JAP, MMA, EM and MAS. Study supervision: EM and AR-T.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.