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Saitta D, Henneken LM, Apputhurai P, Chen Yi Mei SL, Tye-Din JA. Budesonide Induces Favourable Histologic and Symptomatic Recovery in Patients with Non-responsive and Refractory Coeliac Disease When Given in an Open Capsule Format. Dig Dis Sci 2024; 69:2548-2557. [PMID: 38683433 PMCID: PMC11258102 DOI: 10.1007/s10620-024-08436-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Non-responsive coeliac disease (NRCD), where symptoms and enteropathy persist despite a prolonged gluten-free diet (GFD), is common. Refractory coeliac disease (RCD), characterised by malabsorption and extensive enteropathy, is rare but serious. In both, treatment options are limited. Topical budesonide may help and an open capsule format promoting proximal small intestinal delivery may be advantageous. AIM To describe the effect of budesonide and its presentation on mucosal healing, symptoms, and tolerability in NRCD and RCD. METHODS A retrospective cohort study of NRCD and RCD patients who received budesonide for enteropathy despite a strict GFD for over 12 months. Primary outcome was improvement in histology. Symptoms and adverse treatment effects were recorded. RESULTS 50 patients with NRCD (n = 14; 86% F), RCD type 1 (n = 30; 60% F), and RCD type 2 (n = 6 based on aberrant duodenal T cells; 33% F) were identified. Common RCD symptoms were diarrhoea (68%), fatigue (40%), and weight loss (34%). 16 received closed capsule budesonide (CCB) 9 mg OD and 35 open capsule budesonide (OCB) 3 mg 3 times a day. Complete and partial mucosal healing was significantly higher after OCB compared to CCB (p < 0.001, Mann-Whitney U test). Symptom improvement was also significantly higher after OCB compared to CCB (p = 0.002, Mann-Whitney U test). Side effects were mild and self-limiting and were reported in 25% of both cohorts. CONCLUSION OCB was well tolerated and associated with improvements in enteropathy (83%) and symptoms (90%) in NRCD and RCD. Our findings support OCB as the preferred 1st-line therapy for NRCD and RCD type 1.
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Affiliation(s)
- Daniel Saitta
- Department of Gastroenterology, Western Hospital, Footscray, VIC, Australia
| | - Lee M Henneken
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC, Australia
| | - Pragalathan Apputhurai
- Department of Health Sciences and Biostatistics, Swinburne University of Technology, Melbourne, Australia
| | - Swee Lin Chen Yi Mei
- Department of Gastroenterology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Jason A Tye-Din
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia.
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC, Australia.
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
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Discepolo V, Kelly CP, Koning F, Schuppan D. How Future Pharmacologic Therapies for Celiac Disease Will Complement the Gluten-Free Diet. Gastroenterology 2024; 167:90-103. [PMID: 38604542 DOI: 10.1053/j.gastro.2024.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/13/2024]
Abstract
The only proven treatment for celiac disease is adherence to a strict, lifelong, gluten-free diet. However, complete dietary gluten avoidance is challenging and a substantial number of patients do not respond fully, clinically, or histologically, despite their best efforts. As celiac disease is common and its central pathophysiology is well elucidated, it has become attractive for drug development to address the limitations of dietary treatment. Most efforts address nonresponsive celiac disease, defined as continued symptoms and/or signs of disease activity despite a gluten-free diet, and the more severe forms of refractory celiac disease, types I and II. An increasing spectrum of therapeutic approaches target defined mechanisms in celiac disease pathogenesis and some have advanced to current phase 2 and 3 clinical studies. We discuss these approaches in terms of potential efficiency, practicability, safety, and need, as defined by patients, regulatory authorities, health care providers, and payors.
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Affiliation(s)
- Valentina Discepolo
- Department of Translational Medical Science and European Laboratory for the Investigation of Food Induced Diseases, University of Naples Federico II, Naples, Italy.
| | - Ciarán P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Frits Koning
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Detlef Schuppan
- Celiac Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Institute of Translational Immunology and Research Center for Immunotherapy, Center for Celiac Disease and Autoimmunity, Johannes-Gutenberg University, Mainz, Germany.
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Ibrahim AA, Kenyon V, Fasano A, Leonard MM. Budesonide and the Gluten Containing Elimination Diet as Treatments for Non-responsive Celiac Disease in Children. J Pediatr Gastroenterol Nutr 2022; 75:616-622. [PMID: 36305882 PMCID: PMC9627632 DOI: 10.1097/mpg.0000000000003596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Non-responsive celiac disease (NRCD) is defined as patients having persistent symptoms and enteropathy (Marsh 3 histology) suggestive of active celiac disease (CeD), after following a gluten-free diet (GFD) for at least 12 months. NRCD is suggested to affect 15% of children with CeD but data are limited and there is no research to date describing treatment of children with this condition. The aim of this study was to describe our center's approach to identifying and treating NRCD with budesonide and the Gluten Containing Elimination Diet (GCED). METHODS We performed a retrospective, single center analysis over a 5-year period of patients with CD less than 18 years of age (inclusive) who underwent treatment for persistent symptoms and enteropathy despite following a GFD. RESULTS We identified 22 patients with NRCD. Thirteen were treated with the GCED for 3 months with 46% achieving both histological and symptomatic resolution. Nine patients were treated with budesonide (6-9 mg), with 89% achieving both symptomatic and histologic resolution after a median 3-month treatment course. Further, 67% of patients who responded to the GCED and 100% of patients who responded to budesonide remained in remission for at least 6 months following treatment transition back to exclusive GFD. CONCLUSIONS The GCED and budesonide can provide benefit for NRCD. Most patients with NRCD can return to a GFD after 3 months of treatment.
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Affiliation(s)
- Awab Ali Ibrahim
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Victoria Kenyon
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA 02115, USA
- Center for Celiac Research and Treatment, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, MA 02129, USA
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, USA
| | - Alessio Fasano
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA 02115, USA
- Center for Celiac Research and Treatment, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, MA 02129, USA
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, USA
| | - Maureen M. Leonard
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA 02115, USA
- Center for Celiac Research and Treatment, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA 02114, USA
- Mucosal Immunology and Biology Research Center, MassGeneral Hospital for Children, Boston, MA 02129, USA
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, USA
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Enteric-Release Budesonide May Be Useful in the Management of Non-Responsive Celiac Disease. Dig Dis Sci 2021; 66:1989-1997. [PMID: 32654085 PMCID: PMC8515997 DOI: 10.1007/s10620-020-06454-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-responsive celiac disease (NRCD) has many aetiologies, including gluten exposure. Budesonide may be used for refractory celiac disease (RCD) and celiac crisis. AIMS We reviewed the effectiveness of budesonide to induce clinical and histologic response in NRCD with villous atrophy (VA). METHODS Case series of adult cases with NRCD and VA prescribed budesonide at two celiac centers. Clinical variables and mucosal recovery (i.e., normal villous architecture within 1 year of treatment) were evaluated. RESULTS Forty-two cases [77% female, median age 45.0 (IQR 28.3-60.0) years] were included. Most common symptoms were diarrhea (64%) and abdominal pain (62%). Budesonide was initiated at 9 mg (83%) for a median duration of 16.0 weeks (IQR 6.8-25.0 weeks). In total, 57% exhibited a clinical response, positively associated with diarrhea (adjusted OR 6.08 95% CI 1.04-35.47) and negatively with fatigue (adjusted OR 0.18 95% CI 0.03-0.98). Clinical response was higher among those with dietitian counseling prior to budesonide (n = 29, 70 vs. 23%, p < 0.01). Mucosal recovery was observed in 11/24 with follow-up duodenal biopsies. There was no association between clinical response and mucosal recovery, and 79% of clinical responders had a symptomatic relapse. RCD (48%) and chronic gluten exposure (24%) were the main suspected aetiologies of NRCD. Most individuals without a clinical response subsequently received an IBS-related diagnosis. CONCLUSIONS Budesonide may be effective to induce clinical response in NRCD presenting with diarrhea and VA, but clinical recurrence and lack of mucosal recovery are frequent after tapering. Other diagnoses, including coexisting IBS, may be considered in non-responders to budesonide therapy.
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Abstract
Celiac disease is a common form of enteropathy with frequent extraintestinal manifestations (EIM). Misrecognition of these presentations may lead to significant delays in diagnosis. Any organ may be involved, either through an immune/inflammatory phenomenon, or nutritional deficiencies. Some EIM, such as gluten ataxia, may be irreversible if left untreated, but most will improve with a gluten-free diet. Knowledge of the various EIM, as well as the associated conditions which do not improve on a gluten-free diet, will avoid delays in the diagnosis and management of celiac disease and associated manifestations.
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Affiliation(s)
- Amelie Therrien
- Department of Medicine, Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center
- Celiac Research Program, Harvard Medical School
| | - Ciaran P Kelly
- Department of Medicine, Celiac Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center
- Celiac Research Program, Harvard Medical School
| | - Jocelyn A Silvester
- Celiac Research Program, Harvard Medical School
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children Hospital, Boston, MA
- Rady College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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