Coeliac disease is generally well controlled with gluten-free diet but a small proportion of patients require corticosteroids or immunomodulatory agents. Response to anti-tumour necrosis factor (anti-TNF) agents raises interesting questions about both the pathogenesis of coeliac disease and the mechanism of action of anti-TNF agents. Refractory coeliac disease poses a therapeutic challenge to clinicians and carefully selected patients may benefit from anti-TNF therapy.