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Abstract
Celiac disease (CeD) is a chronic immune-mediated enteropathy, which occurs in genetically predisposed individuals by the ingestion of gluten proteins present in wheat, barley and rye. The global pooled prevalence of CeD is 0.7% and it has been reported from nations all around the globe and can affect individuals of any age. It has a wide clinical spectrum ranging from being asymptomatic to being symptomatic with severe manifestations. Though initial descriptions of CeD focused on the classical presentation with gastrointestinal manifestations, in recent years it has been found that more patients have non-classical manifestations such as anemia, osteoporosis, increased transaminases, failure to thrive or short stature. The definitive diagnosis of CeD is based on a combination of clinical history, serologic testing with/without examination of duodenal biopsies. The preferred initial serologic test regardless of age for the detection of CeD is the tissue transglutaminase (IgA anti-tTG). Children with a high tTG-IgA (≥10 ULN) AND a positive anti-endomysial IgA antibody (EMA) can be diagnosed to have CeD without the need for duodenal biopsies. The rest should undergo biopsies with at least 4 biopsies from the distal duodenum and at least 1 from the bulb. A correctly orientated biopsy showing increased intraepithelial cells and a villous to crypt ratio of <2 is suggestive of CeD. The management of CeD is a lifelong complete dietary avoidance of gluten. IgA-TGA acts as a surrogate marker for healing of the small-bowel mucosa and should be performed every 6 mo until normalization and then every 12-24 mo thereafter.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, 501, Stanley Street, South Brisbane, QLD, 4101, Australia.
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, 501, Stanley Street, South Brisbane, QLD, 4101, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
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Lebwohl B, Ma C, Lagana SM, Pai RK, Baker KA, Zayadi A, Hogan M, Bouma G, Cellier C, Goldsmith JD, Lundin KEA, Pinto-Sanchez MI, Robert ME, Rubio-Tapia A, Sanders DS, Schaeffer DF, Semrad CE, Silvester JA, Verdú EF, Verma R, Wu TT, Feagan BG, Crowley E, Jairath V, Murray JA. Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study. Gastroenterology 2024; 166:88-102. [PMID: 37704112 DOI: 10.1053/j.gastro.2023.08.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND & AIMS There is a need to develop safe and effective pharmacologic options for the treatment of celiac disease (CeD); however, consensus on the appropriate design and configuration of randomized controlled trials (RCTs) in this population is lacking. METHODS A 2-round modified Research and Development/University of California Los Angeles Appropriateness Method study was conducted. Eighteen gastroenterologists (adult and pediatric) and gastrointestinal pathologists voted on statements pertaining to the configuration of CeD RCTs, inclusion and exclusion criteria, gluten challenge, and trial outcomes. Two RCT designs were considered, representing the following distinct clinical scenarios for which pharmacotherapy may be used: trials incorporating a gluten challenge to simulate exposure; and trials evaluating reversal of histologic changes, despite attempted adherence to a gluten-free diet. Each statement was rated as appropriate, uncertain, or inappropriate, using a 9-point Likert scale. RESULTS For trials evaluating prevention of relapse after gluten challenge, participants adherent to a gluten-free diet for 12 months or more with normal or near-normal-sized villi should be enrolled. Gluten challenge should be FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) free, and efficacy evaluated using histology with a secondary patient-reported outcome measure. For trials evaluating reversal of villus atrophy, the panel voted it appropriate to enroll participants with a baseline villus height to crypt depth ratio ≤2 and measure efficacy using a primary histologic end point. Guidance for measuring histologic, endoscopic, and patient-reported outcomes in adult and pediatric patients with CeD are provided, along with recommendations regarding the merits and limitations of different end points. CONCLUSIONS We developed standardized recommendations for clinical trial design, eligibility criteria, outcome measures, gluten challenge, and disease evaluations for RCTs in patients with CeD.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada.
| | - Stephen M Lagana
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Rish K Pai
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | | | | | | | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - Christophe Cellier
- Department of Gastroenterology, University of Paris-Cité, Georges-Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Knut E A Lundin
- Norwegian Coeliac Disease Research Centre, University of Oslo Faculty of Medicine, Oslo, Norway; Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Maria I Pinto-Sanchez
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Alberto Rubio-Tapia
- Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - David F Schaeffer
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Carol E Semrad
- Department of Gastroenterology, University of Chicago, Chicago, Illinois
| | - Jocelyn A Silvester
- Harvard Celiac Research Program, Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Celiac Disease Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ritu Verma
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago, Chicago, Illinois
| | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Eileen Crowley
- Alimentiv Inc, London, Ontario, Canada; Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital Western Ontario, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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McDermid JM, Almond MA, Roberts KM, Germer EM, Geller MG, Taylor TA, Sinley RC, Handu D. Celiac Disease: An Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2023; 123:1793-1807.e4. [PMID: 37499866 DOI: 10.1016/j.jand.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Celiac disease is an autoimmune disorder in which the immune system of genetically susceptible individuals elicits a reaction to gluten causing small intestine damage. If left undiagnosed and untreated, the resulting nutrition malabsorption can lead to anemia, bone disease, growth faltering, or other consequences. The condition is lifelong and lacks a cure; the only treatment is lifelong adherence to a gluten-free diet (GFD). This diet is challenging to follow and adversely influences quality of life; however, it is essential to ensure intestinal recovery and prevent future negative health consequences. The Academy of Nutrition and Dietetics convened an expert panel complemented by a celiac disease patient advocate to evaluate evidence for six topics, including medical nutrition therapy; the GFD; oat consumption; micronutrients; pro-/prebiotics; and the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. This publication outlines the Academy of Nutrition and Dietetics Evidence Analysis Library methods used to complete the systematic review and guideline development, and summarizes the recommendations and supporting evidence. The guidelines affirm that all individuals with celiac disease should follow a GFD (1C, Imperative) that may include gluten-free oats in adults (2D, Conditional). Children should follow a nutritionally adequate GFD that supports healthy growth and development (Consensus, Imperative) and does not unnecessarily restrict gluten-free oats (Consensus, Conditional). The guidelines indicate nutritional care should include routine nutritional assessment (Consensus, Imperative) and medical nutrition therapy (Consensus, Imperative). At this time, the guidelines do not support a recommendation for the addition of the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (2C, Conditional); prebiotic or probiotic supplementation (2D, Conditional); or micronutrient supplementation (in the absence of nutritional deficiency) (Consensus, Conditional). The 2021 Celiac Disease Evidence-Based Nutrition Guideline will assist registered dietitian nutritionists in providing appropriate evidence-based medical nutrition therapy to support people with celiac disease in achieving and maintaining nutritional health and avoiding adverse celiac disease consequences throughout their lives.
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Affiliation(s)
| | - M Angie Almond
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Emily M Germer
- Matthew Walker Comprehensive Health Center, Nashville, Tennessee
| | | | | | | | - Deepa Handu
- Academy of Nutrition and Dietetics, Chicago, Illinois.
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Jaglan A, Sadera G, Singh P, Singh BP, Goel G. Probiotic potential of gluten degrading Bacillus tequilensis AJG23 isolated from Indian traditional cereal-fermented foods as determined by Multiple Attribute Decision-Making analysis. Food Res Int 2023; 174:113516. [PMID: 37986423 DOI: 10.1016/j.foodres.2023.113516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 11/22/2023]
Abstract
The present study reported the characterization of gluten hydrolyzing strains of Bacillus sp. from fermented cereal dough. The strains were characterized for probiotic as well as technological attributes. A total of 45 presumptive gluten degrading isolates were obtained on gliadin agar plate assay. Based on hemolytic and antibiotic susceptibility pattern, only six isolates were considered safe which also indicated gliadinase activity on zymography. All the six strains were able to resist the pH 2.0, 0.25% bile and also possessed ability to adhere to the organic solvents and mucin. The cell free supernatant of five strains exhibited antimicrobial activities against Gram-positive and Gram-negative pathogens. A more than 50% survival of the isolated strains was obtained at a salt concentration of 2%, phenol concentration of 0.1% and temperature upto 45 °C. All the strains exhibited antioxidant activities and biofilm forming ability. Furthermore, the ranking of strains based on probiotic as well as other functional attributes was determined using multidimensional Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS). A matrix of multidimensional indicators was prepared using alternatives and criteria, the analysis indicated the strain Bacillus tequilensis AJG23 as the potential probiotic candidate based on all screening criteria. Further work still needs to be done about the protective role of the potential strain against gluten sensitivity using in vitro models.
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Affiliation(s)
- Anjali Jaglan
- Department of Microbiology, Central University of Haryana, Mahendergarh 123031, India
| | - Gunjan Sadera
- Department of Microbiology, Central University of Haryana, Mahendergarh 123031, India
| | - Phool Singh
- School of Engineering and Technology, Central University of Haryana, Mahendergarh 123031, India
| | - Brij Pal Singh
- Department of Microbiology, Central University of Haryana, Mahendergarh 123031, India
| | - Gunjan Goel
- Department of Microbiology, Central University of Haryana, Mahendergarh 123031, India.
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Machado MV. New Developments in Celiac Disease Treatment. Int J Mol Sci 2023; 24:ijms24020945. [PMID: 36674460 PMCID: PMC9862998 DOI: 10.3390/ijms24020945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/18/2022] [Accepted: 01/01/2023] [Indexed: 01/06/2023] Open
Abstract
Celiac disease (CD) is a common autoimmune disease affecting around 1% of the population. It consists of an immune-mediated enteropathy, triggered by gluten exposure in susceptible patients. All patients with CD, irrespective of the presence of symptoms, must endure a lifelong gluten-free diet (GFD). This is not an easy task due to a lack of awareness of the gluten content in foods and the extensive incorporation of gluten in processed foods. Furthermore, a GFD imposes a sense of limitation and might be associated with decreased quality of life in CD patients. This results in gluten contamination in the diet of four out of five celiac patients adhering to a GFD. Furthermore, one in three adult patients will report persistent symptoms and two in three will not achieve full histological recovery when on a GFD. In recent years, there has been extensive research conducted in the quest to find the holy grail of pharmacological treatment for CD. This review will present a concise description of the current rationale and main clinical trials related to CD drug therapy.
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Affiliation(s)
- Mariana Verdelho Machado
- Gastroenterology Department, Hospital de Vila Franca de Xira, Estrada Carlos Lima Costa, Nª 2, 2600-009 Vila Franca de Xira, Portugal; ; Tel.: +351-263-006-500
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Avenida Prof. Egas Moniz, 1649-028 Lisbon, Portugal
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Paolella G, Sposito S, Romanelli AM, Caputo I. Type 2 Transglutaminase in Coeliac Disease: A Key Player in Pathogenesis, Diagnosis and Therapy. Int J Mol Sci 2022; 23:ijms23147513. [PMID: 35886862 PMCID: PMC9318967 DOI: 10.3390/ijms23147513] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Type 2 transglutaminase (TG2) is the main autoantigen in coeliac disease (CD), a widespread inflammatory enteropathy caused by the ingestion of gluten-containing cereals in genetically predisposed individuals. As a consequence, serum antibodies to TG2 represent a very useful marker in CD diagnosis. However, TG2 is also an important player in CD pathogenesis, for its ability to deamidate some Gln residues of gluten peptides, which become more immunogenic in CD intestinal mucosa. Given the importance of TG2 enzymatic activities in CD, several studies have sought to discover specific and potent inhibitors that could be employed in new therapeutical approaches for CD, as alternatives to a lifelong gluten-free diet. In this review, we summarise all the aspects regarding TG2 involvement in CD, including its enzymatic reactions in pathogenesis, the role of anti-TG2 antibodies in disease management, and the exploration of recent strategies to reduce deamidation or to use transamidation to detoxify gluten.
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Affiliation(s)
- Gaetana Paolella
- Department of Chemistry and Biology, University of Salerno, 84084 Fisciano, SA, Italy; (S.S.); (A.M.R.)
- Correspondence: (G.P.); (I.C.)
| | - Silvia Sposito
- Department of Chemistry and Biology, University of Salerno, 84084 Fisciano, SA, Italy; (S.S.); (A.M.R.)
| | | | - Ivana Caputo
- Department of Chemistry and Biology, University of Salerno, 84084 Fisciano, SA, Italy; (S.S.); (A.M.R.)
- European Laboratory for the Investigation of Food-Induced Diseases (ELFID), University of Salerno, 84084 Fisciano, SA, Italy
- Correspondence: (G.P.); (I.C.)
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