[Retrospective evaluation of the ten-year experience of a single coeliac centre]

Novel Therapies for Celiac Disease: A Clinical Review Article

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

Clinical Presentation Is Dependent on Age and Calendar Year of Diagnosis in Celiac Disease: A Hungarian Cross-Sectional Study

International trends indicate that celiac disease (CeD) is becoming more common, while the clinical presentation of CeD tends to change. We aimed to investigate factors associated with the clinical presentation of CeD. We reviewed all CeD cases diagnosed at our tertiary center, University of Pécs (Hungary), between 1992 and 2019. We collected data of verified CeD patients on clinical presentations (classified by the Oslo Classification), the age at and calendar year of diagnosis, and sex, serology and histology at diagnosis. To assess the associations of baseline variables with clinical presentations, we applied univariate and multivariate (binary logistic regression) statistics. A total of 738 CeD patients were eligible for inclusion. In the univariate analysis, patients with classical CeD were more common in the latest calendar period (p < 0.001) and tended to be older (p = 0.056), but we failed to observe a significant association between the clinical presentation and sex, serology or histology at diagnosis. In the multivariate analysis, only age at diagnosis and calendar year were independently associated with clinical presentations (OR = 1.02, CI: 1.01-1.04 and OR = 0.93, CI: 0.89-0.98, respectively). Our findings confirmed that classical CeD is independently associated with age at diagnosis and calendar year of diagnosis of CeD, whereas other parameters were not significantly associated with clinical presentations.

Characteristics of gluten-free potato dough and bread with different potato starch-protein ratios

The poor retention of fermentation gases and air is a critical issue for gluten-free (GF) products. To better understand the effect of potato flour on the characteristics of GF bread, the mechanistic relations between potato starch and potato protein in different ratios at 9:1, 8:2, 7:3, 6:4 and 5:5 for GF dough were investigated for viscoelasticity, thermal properties, moisture, microstructures, and bread quality. The results reveal that potato starch had a relatively important role in both dough and bread. The viscous character of dough was highest at a proportion of 6:4, with a more compact microstructure and better bread color, volume, hardness, chewiness, resilience and springiness. With decreasing starch content, the gelatinization and retrogradation enthalpy decreased, and the relaxation time of immobilized water and free water increased significantly. These results are believed to be helpful for processors to develop and optimize GF breads with potato starch and potato protein.

Association Between Inflammatory Bowel Diseases and Celiac Disease: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

There is controversy over the association between celiac disease (CeD) and inflammatory bowel diseases (IBD). We performed a systematic review and meta-analysis to assess evidence for an association between CeD and IBD.

METHODS

We searched databases including MEDLINE, EMBASE, CENTRAL, Web of Science, CINAHL, DARE, and SIGLE through June 25, 2019 for studies assessing the risk of CeD in patients with IBD, and IBD in patients with CeD, compared with controls of any type. We used the Newcastle-Ottawa Scale to evaluate the risk of bias and GRADE to assess the certainty of the evidence.

RESULTS

We identified 9791 studies and included 65 studies in our analysis. Moderate certainty evidence found an increased risk of CeD in patients with IBD vs controls (risk ratio [RR] 3.96; 95% confidence interval [CI] 2.23-7.02) and increased risk of IBD in patients with CeD vs controls (RR 9.88; 95% CI 4.03-24.21). There was low-certainty evidence for the risk of anti-Saccharomyces antibodies, a serologic marker of IBD, in patients with CeD vs controls (RR 6.22; 95% CI 2.44-15.84). There was low-certainty evidence for no difference in risk of HLA-DQ2 or DQ8 in patients with IBD vs controls (RR 1.04; 95% CI 0.42-2.56), and very low-certainty evidence for an increased risk of anti-tissue transglutaminase in patients with IBD vs controls (RR 1.52; 95% CI 0.52-4.40). Patients with IBD had a slight decrease in risk of anti-endomysial antibodies vs controls (RR 0.70; 95% CI 0.18-2.74), but these results are uncertain.

CONCLUSIONS

In a systematic review and meta-analysis, we found an increased risk of IBD in patients with CeD and increased risk of CeD in patients with IBD, compared with other patient populations. High-quality prospective cohort studies are needed to assess the risk of CeD-specific and IBD-specific biomarkers in patients with IBD and CeD.

Evolving Therapy for Celiac Disease

Gluten is known to be the main triggering factor for celiac disease (CeD), an immune-mediated disorder. CeD is therefore managed using a strict and lifelong gluten-free diet (GFD), the only effective treatment available currently. However, the GFD is restrictive. Hence, efforts are being made to explore alternative therapies. Based on their mechanisms of action on various molecular targets involved in the pathogenesis of CeD, these therapies may be classified into one of the following five broad approaches. The first approach focuses on decreasing the immunogenic content of gluten, using strategies like genetically modified wheat, intra-intestinal gluten digestion using glutenases, microwave thermal treatment of hydrated wheat kernels, and gluten pretreatment with either bacterial/ fungal derived endopeptidases or microbial transglutaminase. The second approach involves sequestering gluten in the gut lumen before it is digested into immunogenic peptides and absorbed, using binder drugs like polymer p(HEMA-co-SS), single chain fragment variable (scFv), and anti- gluten antibody AGY. The third approach aims to prevent uptake of digested gluten through intestinal epithelial tight junctions, using a zonulin antagonist. The fourth approach involves tissue transglutaminase (tTG) inhibitors to prevent the enhancement of immunogenicity of digested gluten by the intestinal tTG enzyme. The fifth approach seeks to prevent downstream immune activation after uptake of gluten immunogenic peptides through the intestinal mucosal epithelial layer. Examples include HLA-DQ2 blockers that prevent presentation of gluten derived- antigens by dendritic cells to T cells, immune- tolerizing therapies like the vaccine Nexvax2 and TIMP-Glia, cathepsin inhibitors, immunosuppressants like corticosteroids, azathioprine etc., and anti-cytokine agents targeting TNF-α and interleukin-15. Apart from these approaches, research is being done to evaluate the effectiveness of probiotics/prebiotics, helminth therapy using Necator americanus, low FODMAP diet, and pancreatic enzyme supplementation in CeD symptom control; however, the mechanisms by which they play a beneficial role in CeD are yet to be clearly established. Overall, although many therapies being explored are still in the pre-clinical phase, some like the zonulin antagonist, immune tolerizing therapies and glutenases have reached phase II/III clinical trials. While these potential options appear exciting, currently they may at best be used to supplement rather than supplant the GFD.

Coeliac disease in a 15-year period of observation (1997 and 2011) in a Hungarian referral centre

AIMS

The aim of this study is to evaluate the experience of a single coeliac centre over a 15-year-long study period (between November of 1997 and September of 2011).

PATIENTS AND METHODS

Charts of 178 patients (139 females) with coeliac disease were retrospectively evaluated. Tests performed: multiple duodenal biopsies, anti-tissue transglutaminase and anti-endomysium antibodies, body mass index calculation, osteodensitometry, evaluation of disorders associated with coeliac disease, and implementation of family screening.

RESULTS

Histological samples were available in 133 cases, distribution according to Marsh-Oberhuber classification: M0 in 7%, M1-M2 in 4%, M3a in 26%, M3b in 13%, and M3c in 50% of cases, respectively. Anti-tissue transglutaminase and anti-endomysium antibody tests were available in 158 cases, 132/158 showed seropositivity. Mean body mass index values were 23.05kg/m(2) for males, and 21.07kg/m(2) for females, respectively. Osteodensitometry showed normal values in 46%, osteopenia in 36%, and osteoporosis in 18% of cases, respectively. Coeliac disease associated disorders was present in 63/178 (35%) patients. Ninety coeliacs brought 197 first degree relatives for screening, with 47/197 (23%) relatives proving to have coeliac disease. Correlations between anti-tissue transglutaminase antibody titres and Marsh-Oberhuber classification, and anti-tissue transglutaminase antibody titres and bone mineral density values were found to be statistically significant (p=0.0011, and p=0.001, respectively).

CONCLUSIONS

Coeliac disease can become overt at any age. Female predominance is significant. Histology usually showed advanced villous atrophy. Mean body mass index values were within normal range. The high prevalence of associated disorders is also noted. The prevalence of 24% of coeliac disease among first degree relatives underlines the necessity of family screening.