# Presentation: 900877

## Prospective  Studies on Celiac Disease

**Alessio Fasano and Carlo Catassi**
**Center for Celiac Research**
**University of Maryland School of Medicine**

## On the Coeliac Affection 

**There is a kind of chronic indigestion which is met with in persons of all ages, yet is especially apt to affect children between one and five years old.... **

**Signs of the disease are yielded by the faeces; being loose, not formed, but not watery; more bulky than the food taken would seem to account for... **

**The causes of the disease are obscure. Children who suffer from it are not all weak in constitution. Errors in diet may perhaps be a cause, but what error? Why, out of a family of children all brought up in much the same way, should one alone suffer? **

**Gee S. On the celiac affection. St Bart Hosp Rep 1890; 24: 17-20.**** **

*On the Coeliac Affection *

## Definition

**Celiac disease is an autoimmune condition**
**Occurs in genetically susceptible individuals**
**DQ2 and/or DQ8 positive HLA haplotype is necessary but not sufficient**
**A *****unique***** autoimmune disorder because:**
**both the environmental trigger (gluten) and the autoantigen (tissue Transglutaminase) are known**
**elimination of the environmental trigger leads to a complete resolution of the disease**

## Pathogenesis

**Genetic predisposition**
**Environmental triggers**
**Dietary **
**Non dietary?**

## 
Several genes are involved
The most consistent genetic component   depends on the presence of HLA-DQ             (DQ2 and / or DQ8) genes
Other genes (not yet identified) account for 60 % of the inherited component of the disease
HLA-DQ2 and / or DQ8 genes are necessary   (No DQ2/8, no Celiac Disease!) but not sufficient for the development of the disease

**Several genes are involved**
**The most consistent genetic component   depends on the presence of HLA-DQ             (DQ2 and / or DQ8) genes**
**Other genes (not yet identified) account for 60 % of the inherited component of the disease**
**HLA-DQ2 and / or DQ8 genes are necessary   ****(No DQ2/8, no Celiac Disease!)**** but not sufficient for the development of the disease**

**HLA**

**?**

**?**

**?**

**?**

**Gluten**

**Celiac Disease**

**+**

**Genes**

**Genetics**

## {

***DQA1*0501***

***DQB1*0201***

**DQ2**

***DQA1*0201***

**DR3**

**CIS**

**DR5/DR7**

**Trans**

**DR3/DR3**

**CIS**

***DQB1*03***

**DQA: Any**

**APC**

**Gluten**

**DQ2**

**DQ8**

**Be aware DR3 should now be referred to as DR17**

## Dietary Factors

**Festucoideae**

_**Subfamily**_
_**Tribe**_

**Zizaneae****	****       Oryzeae****	****       Hordeae****	****      Aveneae****	****     Festuceaea****	****      Chlorideae**

**wild rice****	****     rice****	****       wheat****	****           oat****	****         finger millet****	****             teff**
**	****	****	****	****                ****(ragi)**

**rye**
**barley**

**The Grass Family - ****(GRAMINEAE)**

## The Celiac Iceberg

**Symptomatic**
**Celiac Disease**

**Silent Celiac **
**Disease**

**Latent Celiac Disease**

** ****Genetic ****susceptibility: ****-  DQ2, DQ8**
**                  ****Positive serology****	**

**Manifest **
**mucosal lesion**

**Normal **
**Mucosa**

## Treatment Options

## Treatment

**Only treatment for celiac disease is a gluten-free diet (GFD)**
**Strict, lifelong diet**
**Avoid:**
**Wheat**
**Rye**
**Barley  **

## Gluten-Containing Grains to Avoid

**Wheat****	****Bulgar****	****Filler**
**Wheat Bran****	****Couscous****	****Graham flour**
**Wheat Starch****	****Durum****	****Kamut**
**Wheat Germ****	****Einkorn****	****Matzo**
**Flour/Meal****	****Barley****	****Emmer**
**Semolina****	****Barley Malt/ Extract****	****Faro****	**
**Spelt****	****Rye****	****Triticale**

## Sources of Gluten

**OBVIOUS SOURCES**
**Bread**
**Bagels**
**Cakes**
**Cereal**
**Cookies**
**Pasta / noodles**
**Pastries / pies**
**Rolls**

## Sources of Gluten

**POTENTIAL SOURCES**
**Candy**
**Communion wafers**
**Cured Pork Products**
**Drink mixes**
**Gravy**
**Imitation meat / seafood**
**Sauce**
**Self-basting turkeys**
**Soy sauce**

## Gluten-Free Grains and Starches

**Arrowroot **
**Buckwheat **
**Corn**
**Flax**
**Millet**
**Montina**
**Oats* **

**Potato **
**Quinoa **
**Rice**
**Sorghum**
**Tapioca**
**Teff**
**Flours made from nuts, beans and seeds**

**Gluten-Free Grains and Starches**

***for possible cross-contamination with gluten containing grains**

## Other Items to Consider

**Lipstick/Gloss/Balms**
**Mouthwash/Toothpaste**
**Play Dough**
**Stamp and Envelope Glues**
**Vitamin, Herbal, and **
**	****Mineral preparations**
**Prescription or OTC Medications**

## Only 50% of Americans with a chronic illness adhere to their treatment regimen including: 
diet
exercise 
medication
Dietary compliance can be the most difficult aspect of treatment

**diet**
**exercise **
**medication**
**Dietary compliance can be the most difficult aspect of treatment**

**Dietary Adherence:****A Common Problem**

**Notes:**
50%: J. Paediatr. Child Health (2003) 39: 2-5. 
Most difficult: Heart and Lung (2001) 30:294-301.; Heart and Lung (1995) 24:359-368.; Nephrol Dial Transplant (2003) 18:1869-1873.; Lancet (2002) 360:55-57.; J. Am. Diet Assoc. (2004) 104:35-41. 
Italian Study: Digestion (2002) 66:178-185. 

Research has consistently demonstrated that despite life-threatening effects, patients on dialysis, in heart failure and PKU (among others) are likely to be non-compliant with the diet that is necessary to manage their condition. Side effects from non-compliance were debilitating, ongoing and often required medical treatment, yet patients often continued to eat the foods that caused these symptoms. Knowledge about the special diet, or about the condition did not positively influence compliance in these patients—studies demonstrated that symptoms did not influence a patient’s choice to eat forbidden foods.

In comparison, most patients with celiac disease who are non-compliant do not experience crippling symptoms, if they feel the effects at all. Fasano, et.al demonstrated in a US study on the prevalence of celiac disease that a majority of the patients are diagnosed with a Marsh 2 lesion, and a significant percentage (up to 40% in adults and 60% in children) did not experience symptoms at all. It is not surprising, given this evidence, that it might be more difficult for celiacs believe that a 100% gluten-free diet is truly necessary to manage a condition that many do not even notice. 
Estimates of compliance in celiac patients varies; one 2002 study noted that 56% of patients were non compliant after an average of seven years on the diet. 

## Health Beliefs of Adults with Celiac Disease

**Survey of 100 people in Celiac Disease support group (Buffalo, NY)**
**Number of people who agreed with following statements:**
**“****If I eat less gluten I will have less intestinal damage.” –51%**
**“****I’ve lived this long eating gluten, how much will the gluten-     free diet really help me now?” –33%**
**“****My doctor should be the one to tell me when I need follow   up testing.” –26%**
**“****Scientist/doctors still haven’t proven that gluten really hurts them.” –16%**

**Notes:**
Pilot Study conducted by the University of Chicago Celiac Disease Program, in 2004, as part of its national education campaign called “Taming Temptation: Practical Strategies for Maintaining a 100% Gluten-Free Diet”   Participants were asked to agree or disagree with a series of statements reflecting health beliefs about celiac disease in order to establish some of the reasons that people with celiac disease may cheat on the diet. The beliefs expressed by this group of celiacs highlights the challenges faced by medical professionals who diagnose and treat people with celiac disease. 

40% did not return survey
63% diagnosed since 2000

## Barriers to Compliance

**Ability to manage emotions – depression, anxiety**
**Ability to resist temptation – exercising restraint**
**Feelings of deprivation**
**Fear generated by **
**	****inaccurate information **

**Notes:**
J. Am. Diet. Assoc. (1994) 94(8): 874-876.
This list of obstacles was adapted from a list generated by people with diabetes. The practical, social and emotional impact of a celiac diagnosis is an ever present reality for a person with the condition. No longer able to take the convenience, availability or content of food for granted, a celiac must remain armed with the knowledge of a food scientist, the savvy of a world class chef schooled in all aspects of food preparation, and the ability to anticipate and prepare for the need to bring along gluten-free alternatives for events, meetings, and dinners out. 

Underlying these practical matters are fears and feelings which impact health behavior. While it is normal to feel angry and overwhelmed at times, medical professionals need to monitor patients who may not be adjusting to the diagnosis as well as could be expected. Depression, anxiety, anger and fear that interfere with daily activities or lead to behaviors like removing more foods than are necessary from the diet requires additional intervention. 

## Barriers to Compliance

**Time pressure – time to plan, prepare food is longer**
**Planning – work required to plan meals**
**Competing priorities – family, job, etc.**
**Assessing gluten content in **
**	****foods/label reading**
**Eating out – avoidance, fear, difficult to ensure food is safe**

## Gluten and treatment of Celiac Disease:
How Much is Too Much?

**How Much is Too Much?**

## The gluten microchallenge study

**Coordinator: Carlo Catassi, M.D.**

## Investigating the dose-effect relationship the gluten microchallenge

**CD patients on long-term, strict GFD**
**Perspective study design**
**While the GFD is maintained throughout the study-period, a given amount of gluten/gliadin is added to the diet**
**Clinical, serological and biopsy evaluation before and after the microchallenge**
**The *****background noise***** caused by possible gluten contamination of the GFD was minimized by inclusion of a control group  **

## DOSE-DEPENDENT EFFECTS OF PROTRACTED INGESTION OF SMALL AMOUNTS OF GLIADIN IN CELIAC CHILDREN

**Positive linear relationship between gliadin daily dose and mucosal damage between 100 and 1000 mg/day**
**IEL count is the most sensitive index**
**Serological markers are not reliable tools for detecting minimal dietary transgressions**

*Catassi et al, Gut 1996*

## Why performinging a new microchallenge study

**Need of investigating the effects of lower gluten doses**
**Need of prolonging the duration of the microchallenge**
**Need of a control group**
**Need of investigating gluten rather than gliadin**

## Gluten and Giadins

- Gluten is the main proteic fraction in wheat (8-14 %);
- The toxicity is mainly due to the gliadins (50 %), however glutenins also contribute to toxicity;
- Daily intake of gluten in adults: ~ 15 g (Dautch data);
- Daily consumption of flower for a typical GFD in celiac subjects: ~ 80 g;
- 200 mg/Kg of gluten = 100 mg/Kg of gliadin = 100 ppm of gliadin (=2.5g of bread!)

**200g**

**Wheat**

**Gluten**

**15g**

**Gliadin**

**7.5g**

**~52 toxic fragments**

## The new microchallenge study 

- AIM
**	****To evaluate the consequences of the protracted ingestion of minimal daily gluten intake (either 10 or 50 mg) in a group of adult celiacs on long-term treatment with the gluten-free diet (GFD)**
- TYPE OF STUDY
**	****Multicentre, prospective, randomized, placebo-controlled, double-blind**
- STUDY PERIOD
**	****Years 2001-2004**
- SPONSOR
**	****Italian Celiac Society (AIC)  **

## The “new” Italian microchallenge study

*INCLUSION CRITERIA*
**Patients with biopsy-proven CD on a GFD for at least 2 years**

*EXCLUSION CRITERIA*
**Younger than 18 yrs**
**Poor compliance to the GFD**
**Abnormal results at the baseline evaluation**
**Associated selective IgA deficiency**

## The Italian microchallenge studyStudy-Design

**Steps**

- GFD  2 yrs

- Running-in

- Baseline

- Microchallenge                      T1

-           GFD

**Intervention**

- Informed
- consent
- Strict
- monitoring
- of the GFD

- Clinical
- Serology
- SB Biopsy

**Patient flow**

- + 50 mg gluten

- + 10 mg gluten

- + 0 mg gluten

**Timeframe**

- Pre-T0

- T0                   1             2

-  3 m

- Randomization                      Clinical
- Gluten exposure                    Serology
- Monthly check                       SB biopsy

- T0

## The Italian microchallenge studyMethods

**Purified gluten was used for the microchallenge study (Amygluten 110, Tate & Lyle, UK)**
**Gluten- or lactose (placebo) containing capsules were centrally prepared**
**All laboratory tests were centrally performed**
**Monthly monitoring of adherence to the protocol**
**Measurement of gluten contamination in commercially available GF food by ELISA (Ridascreen Gliadin, R-Biopharm AG, Germany)**
**Serum AGA (ELISA) and anti-tTG (ELISA)**
**Small bowel biopsy and morphometry on 10 villi, IEL count (CD3+), ab IEL count**
**Control biopsies from non-celiac GE patients**

## Gluten content in commercially-available gluten free products in Italy where currently food labeling policies for gluten free products are set at 20 ppm

## The Italian microchallenge studySubjects completing the study 

## The Italian microchallenge study:Biopsy findings at baseline

**Controls             CD**

**CD3+ T cells (x100 enterocytes)**

## The Italian microchallenge studyBiopsy findings at baseline 

**IEL count (X100 enterocytes)**

**VH/CD Ratio**

## The Italian microchallenge studyClinical findings 

- None					      6	                8	          7
- Abdominal pain and distension		      2	                1                      2
- Anemia and/or iron deficiency		      1		 0	          0
- Loss of appetite				      0		 0	          1
- Bloating, mood changes			      2	               1                      0
- Apthous stomatitis			      0	               0	          **1**
- Constipation      			       	      2	               0                     0
- Headache, abdominal distention	      	      1	               0                     0
- Weight loss                                                           0                      0                     **1**

**The Italian microchallenge study****Clinical findings***** ***

## The Italian microchallenge studySerological findings 

## The Italian microchallenge study

**Morphometry findings****1**

## The Italian microchallenge study

**The Italian microchallenge study**
**Morphometry findings****2**

## The Italian microchallenge study

**Morphometry findings**

## Tolerable daily intake of gluten and ppm of gluten in food for celiacs

|  | 50 g | 100 g | 200 g | 300 g |
| --- | --- | --- | --- | --- |
| 200 ppm | 10 mg | 20 mg | 40 mg | 60 mg |
| 100 ppm | 5 mg | 10 mg | 20 mg | 30 mg |
| 50 ppm | 2.5 mg | 5 mg | 10 mg | 15 mg |
| 20 ppm | 1 mg | 2 mg | 4 mg | 6 mg |

## Toxicity of gluten traces:the Italian study on gluten microchallenge

**Catassi C****1,2****, Fabiani E****1****, Mandolesi A****3****, Bearzi I****3****, Iacono G****4****, **
**D’Agate C****5****, Francavilla R****6****, Corazza GR****7****, Volta U****8****, Accomando S****9****, Picarelli A****10****, De Vitis I****11****, Bardella MT****12****, Pucci A****13****, Fasano A****2**
- 1 Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy; 2 Center For Celiac Research, University of Maryland School of Medicine, Baltimore (USA); 3 Department of Pathology, Università Politecnica delle Marche, Ancona (Italy); 4 Department of Gastroenterology, Children Hospital, Palermo; 5 University Department of Gastroenterology, Catania; 6 University Department of Pediatrics, Bari; 7 University Department of Gastroenterology, Pavia; 8 University Department of Internal Medicine, Bologna; 9 University Department of Pediatrics, Palermo; 10 Department of Gastroenterology, “La Sapienza” University, Rome; 11 University Department of Internal Medicine, “Gemelli” University, Rome; 12 University Department of Medical Sciences, Milan; 13 Italian Celiac Society.