Celiac disease medical therapy: Difference between revisions

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Latest revision as of 20:50, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

A minority of patients suffer from refractory disease, which means that they do not improve with a gluten-free diet. Pharmacotherapy is used if dietary modification is not beneficial. Pharmacotherapy include steroids, azathioprine, cyclosporine, and monoclonal antibodies.

Medical Therapy

Refractory disease

A minority of patients suffer from refractory disease, which means they do not improve on a gluten-free diet. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone or the patient is not adhering to the diet, or the patient is consuming foods that contain gluten. Pharmacotherapy is used if dietary modification is not effective.^[1]

1. Steroids

Preferred regimen(1): Prednisone 0.5–1 mg/kg q24h
Preferred regimen(2): Budesonide 9 mg q24h
Preferred regimen(3): Prednisone 0.5–1 mg/kg q24h and azathioprine 2 mg/kg q24h combination

2. Immunosuppressive drugs (Used in steroid dependent or steroid refractory disease)
- 2.1 Antiproliferative agents
  - Preferred regimen(1): Azathioprine 2 mg/kg q24h
- 2.2 Calcineurin Inhibitors:
  - Preferred regimen(1): Cyclosporine 5 mg/kg q24h PO
- 2.3 Monoclonal antibodies
  - Preferred regimen(1): Infliximab 5 mg/kg q24h
  - Preferred regimen(2): Alemtuzumab 30 mg twice a week per 12 weeks

Dermatitis herpetiformis

1. Life style modification^[2]
- 1.1 Gluten-free diet (GFD)
2. Pharmocatherapy^[3]^[4]
- 2.1 Sulfones
  - Preferred treatment(1): Dapsone 50 mg q24h increased every week until clearance or tolerance
- 2.2 Suhphonamides
  - Alternative treatment (1): Sulfasalazine 500 mg q8h (maximum, 2g q8h)
- 2.3 Combination treatment^[5]
  - Alternative treatment (1): Dapsone plus sulfasalazine
- 2.4 Other treatment (intolerance or allergies to dapsone and sulfasalazine)
  - Alternative treatment (1): Colchicine^[6]
  - Alternative treatment (2): Cholestyramine
  - Alternative treatment (3): Tetracycline^[7]
  - Alternative treatment (4): Niacinamide^[7]
  - Alternative treatment (5): Heparin^[7]
  - Alternative treatment (6): Cyclosporin
- 2.5 Monoclonal antibodies^[8]
  - Preferred treatment(1): Rituximab
  Note: Used is severe cases not improved by other medications.

References

↑ Rubio-Tapia A, Murray JA (2010). "Classification and management of refractory coeliac disease". Gut. 59 (4): 547–57. doi:10.1136/gut.2009.195131. PMC 2861306. PMID 20332526.
↑ Collin P, Reunala T (2003). "Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists". Am J Clin Dermatol. 4 (1): 13–20. PMID 12477369.
↑ Mutasim DF (2007). "Therapy of autoimmune bullous diseases". Ther Clin Risk Manag. 3 (1): 29–40. PMC 1936286. PMID 18360613.
↑ Han A (2009). "A practical approach to treating autoimmune bullous disorders with systemic medications". J Clin Aesthet Dermatol. 2 (5): 19–28. PMC 2924135. PMID 20729961.
↑ Bevans SL, Sami N (2017). "Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis". Int. J. Dermatol. 56 (5): e90–e92. doi:10.1111/ijd.13542. PMID 28133723.
↑ Silvers DN, Juhlin EA, Berczeller PH, McSorley J (1980). "Treatment of dermatitis herpetiformis with colchicine". Arch Dermatol. 116 (12): 1373–84. PMID 7458365.
↑ ^7.0 ^7.1 ^7.2 Shah SA, Ormerod AD (2000). "Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide". Clin. Exp. Dermatol. 25 (3): 204–5. PMID 10844495.
↑ Albers LN, Zone JJ, Stoff BK, Feldman RJ (2017). "Rituximab Treatment for Recalcitrant Dermatitis Herpetiformis". JAMA Dermatol. 153 (3): 315–318. doi:10.1001/jamadermatol.2016.4676. PMID 28030659.

Template:WH Template:WS

[pmid20332526-1] Rubio-Tapia A, Murray JA (2010). "Classification and management of refractory coeliac disease". Gut. 59 (4): 547–57. doi:10.1136/gut.2009.195131. PMC 2861306. PMID 20332526.

[pmid12477369-2] Collin P, Reunala T (2003). "Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists". Am J Clin Dermatol. 4 (1): 13–20. PMID 12477369.

[pmid18360613-3] Mutasim DF (2007). "Therapy of autoimmune bullous diseases". Ther Clin Risk Manag. 3 (1): 29–40. PMC 1936286. PMID 18360613.

[pmid20729961-4] Han A (2009). "A practical approach to treating autoimmune bullous disorders with systemic medications". J Clin Aesthet Dermatol. 2 (5): 19–28. PMC 2924135. PMID 20729961.

[pmid28133723-5] Bevans SL, Sami N (2017). "Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis". Int. J. Dermatol. 56 (5): e90–e92. doi:10.1111/ijd.13542. PMID 28133723.

[pmid7458365-6] Silvers DN, Juhlin EA, Berczeller PH, McSorley J (1980). "Treatment of dermatitis herpetiformis with colchicine". Arch Dermatol. 116 (12): 1373–84. PMID 7458365.

[pmid10844495-7] 7.0 ^7.1 ^7.2 Shah SA, Ormerod AD (2000). "Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide". Clin. Exp. Dermatol. 25 (3): 204–5. PMID 10844495.

[pmid28030659-8] Albers LN, Zone JJ, Stoff BK, Feldman RJ (2017). "Rituximab Treatment for Recalcitrant Dermatitis Herpetiformis". JAMA Dermatol. 153 (3): 315–318. doi:10.1001/jamadermatol.2016.4676. PMID 28030659.

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@@ Line 4: / Line 4: @@
 ==Overview==
-Preferred therapy for celiac disease is dietary modification which includes [[gluten-free diet]]. Patients with celiac disease should be referred to a [[dietitian]] once the diagnosis of celiac disease is made. A minority of patients suffer from refractory disease, which means that they do not improve with a [[gluten-free diet]]. Pharmocotherapy is used if alternative causes are eliminated and dietary modification is not beneficial. Pharmacotherapy include [[Steroid|steroids]], [[azathioprine]], [[Cyclosporine|cyclosporin]], and [[monoclonal antibodies]].
+A minority of patients suffer from refractory disease, which means that they do not improve with a [[gluten-free diet]]. Pharmacotherapy is used if dietary modification is not beneficial. Pharmacotherapy include [[Steroid|steroids]], [[azathioprine]], [[Cyclosporine|cyclosporine]], and [[monoclonal antibodies]].
 ==Medical Therapy==
-*Preferred theray for celiac disease is dietary modification which include [[gluten-free diet]]. <ref name="pmid24355936">{{cite journal |vauthors=Schuppan D, Zimmer KP |title=The diagnosis and treatment of celiac disease |journal=Dtsch Arztebl Int |volume=110 |issue=49 |pages=835–46 |year=2013 |pmid=24355936 |pmc=3884535 |doi=10.3238/arztebl.2013.0835 |url=}}</ref><ref name="pmid15825119">{{cite journal |vauthors=Kupper C |title=Dietary guidelines and implementation for celiac disease |journal=Gastroenterology |volume=128 |issue=4 Suppl 1 |pages=S121–7 |year=2005 |pmid=15825119 |doi= |url=}}</ref>
-*Patient should be referred to a [[dietitian]] once the diagnosis of celiac disease is made.
-===Celiac Disease===
-* 1 '''Dietary modification'''
-** 1.1 '''Gluten-free diet (GFD)'''
-*** 1.1.1 '''Storage protein not allowed'''
-***:* Wheat
-***:* Rye
-***:* Barley
-***:* Spelt
-***:* Kamut
-***:* Emmer wheat
-***:* Einkorn wheat
-***:* Green spelt
-*** 1.1.2 '''Storage protein allowed'''
-**** 1.1.2.1 Comparatively more nutritious (more nutritious than other starches in the GFD; higher fiber, [[protein]], [[calcium]], [[iron]].)
-***** Amaranth
-***** Buckwheat
-***** Legumes
-***** Quinoa
-***** Sorghum/Milo
-***** Soy
-***** Tef/Teff
-**** 1.1.2.2 Comparatively less nutritious
-***** Arrowroot
-***** Corn/maize
-***** Indian Rice Grass (Montina)
-***** Mesquite
-***** Millet
-***** Nuts
-***** Potato
-***** Rice
-***** Tapioca
-***** Wild rice
-*****Pure oats (oats that are not contaminated by gluten)<ref name="pmid17948135">{{cite journal |vauthors=Rashid M, Butzner D, Burrows V, Zarkadas M, Case S, Molloy M, Warren R, Pulido O, Switzer C |title=Consumption of pure oats by individuals with celiac disease: a position statement by the Canadian Celiac Association |journal=Can. J. Gastroenterol. |volume=21 |issue=10 |pages=649–51 |year=2007 |pmid=17948135 |pmc=2658132 |doi= |url=}}</ref>
-***** Wheat starch
-****: '''Note:''' There is evidence that wheat starch is a safe and well-tolerated addition to gluten-free diet.However, wheat starch is not currently accepted in the United States or Canadian GFD.
-** 2.1 '''Nutritional supplements''' (must be strict gluten-free)
-**::* Fiber
-**::* [[Iron supplements|Iron]]
-**::* [[Calcium supplements|Calcium]]
-**::* [[Vitamin D]]
-**::* [[Magnesium]]
-**::* [[Zinc]]
-**::* [[Vitamin B]] complex ([[folate]], [[niacin]], [[vitamin B12]], [[riboflavin]])
-**::: '''Note:'''  Even while on a diet, health-related quality of life (HRQOL) may be decreased in people with celiac disease. Some have persisting digestive symptoms or [[dermatitis herpetiformis]], mouth ulcers, [[osteoporosis]] and [[fractures]]. Symptoms suggestive of [[irritable bowel syndrome]] may be present, and there is an increased rate of [[anxiety]], [[fatigue]], [[dyspepsia]] and [[musculoskeletal pain]].<ref name="pmid16772832">{{cite journal |vauthors=Häuser W, Gold J, Stein J, Caspary WF, Stallmach A |title=Health-related quality of life in adult coeliac disease in Germany: results of a national survey |journal=Eur J Gastroenterol Hepatol |volume=18 |issue=7 |pages=747–54 |year=2006 |pmid=16772832 |doi=10.1097/01.meg.0000221855.19201.e8 |url=}}</ref>
 ===Refractory disease===
-A tiny minority of patients suffer from refractory disease, which means they do not improve on a [[gluten-free diet]]. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone, or because the patient is not adhering to the diet, or because the patient is consuming foods that are inadvertently contaminated with [[gluten]]. Pharmocotherapy is used if alternative cause is elimiated.<ref name="pmid20332526">{{cite journal |vauthors=Rubio-Tapia A, Murray JA |title=Classification and management of refractory coeliac disease |journal=Gut |volume=59 |issue=4 |pages=547–57 |year=2010 |pmid=20332526 |pmc=2861306 |doi=10.1136/gut.2009.195131 |url=}}</ref>
+A minority of patients suffer from refractory disease, which means they do not improve on a [[gluten-free diet]]. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone or the patient is not adhering to the diet, or the patient is consuming foods that contain [[gluten]]. Pharmacotherapy is used if dietary modification is not effective.<ref name="pmid20332526">{{cite journal |vauthors=Rubio-Tapia A, Murray JA |title=Classification and management of refractory coeliac disease |journal=Gut |volume=59 |issue=4 |pages=547–57 |year=2010 |pmid=20332526 |pmc=2861306 |doi=10.1136/gut.2009.195131 |url=}}</ref>
-* 1 '''Steroids'''
+* 1. '''Steroids'''
-:::* Preferred regimen(1): [[Prednisone]] 0.5–1 mg/kg q24h
+::* Preferred regimen(1): [[Prednisone]] 0.5–1 mg/kg q24h
-:::* Preferred regimen(2): [[Budesonide]] 9 mg q24h
+::* Preferred regimen(2): [[Budesonide]] 9 mg q24h
-:::* Preferred regimen(3): [[Prednisone]] 0.5–1 mg/kg q24h and [[azathioprine]] 2 mg/kg q24h combination
+::* Preferred regimen(3): [[Prednisone]] 0.5–1 mg/kg q24h and [[azathioprine]] 2 mg/kg q24h combination
-* 2 '''Immunosupressive drugs''' (Used in steroid dependent or steroid refractory disease)
+* 2. '''Immunosuppressive drugs''' (Used in steroid dependent or steroid refractory disease)
 ** 2.1 '''Antiproliferative agents'''
-:::* Preferred regimen(1): [[Azathioprine]] 2 mg/kg q24h
+*** Preferred regimen(1): [[Azathioprine]] 2 mg/kg q24h
 ** 2.2 '''Calcineurin Inhibitors:'''
-:::* Preferred regimen(1): [[Cyclosporine]] 5 mg/kg q24h PO
+*** Preferred regimen(1): [[Cyclosporine]] 5 mg/kg q24h PO
 ** 2.3 '''Monoclonal antibodies'''
-:::* Preferred regimen(1): [[Infliximab]] 5 mg/kg q24h
+*** Preferred regimen(1): [[Infliximab]] 5 mg/kg q24h
-:::* Preferred regimen(2): [[Alemtuzumab]] 30 mg twice a week per 12 weeks
+*** Preferred regimen(2): [[Alemtuzumab]] 30 mg twice a week per 12 weeks
+===Dermatitis herpetiformis===
+*1. '''Life style modification'''<ref name="pmid12477369">{{cite journal |vauthors=Collin P, Reunala T |title=Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists |journal=Am J Clin Dermatol |volume=4 |issue=1 |pages=13–20 |year=2003 |pmid=12477369 |doi= |url=}}</ref>
+**1.1 '''Gluten-free diet (GFD)'''
+*2. '''Pharmocatherapy'''<ref name="pmid18360613">{{cite journal |vauthors=Mutasim DF |title=Therapy of autoimmune bullous diseases |journal=Ther Clin Risk Manag |volume=3 |issue=1 |pages=29–40 |year=2007 |pmid=18360613 |pmc=1936286 |doi= |url=}}</ref><ref name="pmid20729961">{{cite journal |vauthors=Han A |title=A practical approach to treating autoimmune bullous disorders with systemic medications |journal=J Clin Aesthet Dermatol |volume=2 |issue=5 |pages=19–28 |year=2009 |pmid=20729961 |pmc=2924135 |doi= |url=}}</ref>
+**2.1 '''Sulfones'''
+*** Preferred treatment(1): [[Dapsone]] 50 mg q24h increased every week until clearance or tolerance
+**2.2 '''Suhphonamides'''
+*** Alternative treatment (1):  [[Sulfasalazine]] 500 mg q8h (maximum, 2g q8h)
+**2.3 '''Combination treatment'''<ref name="pmid28133723">{{cite journal |vauthors=Bevans SL, Sami N |title=Dapsone and sulfasalazine combination therapy in dermatitis herpetiformis |journal=Int. J. Dermatol. |volume=56 |issue=5 |pages=e90–e92 |year=2017 |pmid=28133723 |doi=10.1111/ijd.13542 |url=}}</ref>
+*** Alternative treatment (1): [[Dapsone]] plus [[sulfasalazine]]
+**2.4 '''Other treatment''' (intolerance or allergies to dapsone and  [[sulfasalazine]])
+*** Alternative treatment (1): [[Colchicine]]<ref name="pmid7458365">{{cite journal |vauthors=Silvers DN, Juhlin EA, Berczeller PH, McSorley J |title=Treatment of dermatitis herpetiformis with colchicine |journal=Arch Dermatol |volume=116 |issue=12 |pages=1373–84 |year=1980 |pmid=7458365 |doi= |url=}}</ref>
+*** Alternative treatment (2): [[Cholestyramine]]
+*** Alternative treatment (3): [[Tetracycline]]<ref name="pmid10844495">{{cite journal |vauthors=Shah SA, Ormerod AD |title=Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide |journal=Clin. Exp. Dermatol. |volume=25 |issue=3 |pages=204–5 |year=2000 |pmid=10844495 |doi= |url=}}</ref>
+*** Alternative treatment (4): [[Nicotinamide|Niacinamide]]<ref name="pmid10844495">{{cite journal |vauthors=Shah SA, Ormerod AD |title=Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide |journal=Clin. Exp. Dermatol. |volume=25 |issue=3 |pages=204–5 |year=2000 |pmid=10844495 |doi= |url=}}</ref>
+*** Alternative treatment (5): [[Heparin]]<ref name="pmid10844495">{{cite journal |vauthors=Shah SA, Ormerod AD |title=Dermatitis herpetiformis effectively treated with heparin, tetracycline and nicotinamide |journal=Clin. Exp. Dermatol. |volume=25 |issue=3 |pages=204–5 |year=2000 |pmid=10844495 |doi= |url=}}</ref>
+*** Alternative treatment (6): [[Cyclosporine|Cyclosporin]]
+**2.5 '''Monoclonal antibodies'''<ref name="pmid28030659">{{cite journal |vauthors=Albers LN, Zone JJ, Stoff BK, Feldman RJ |title=Rituximab Treatment for Recalcitrant Dermatitis Herpetiformis |journal=JAMA Dermatol |volume=153 |issue=3 |pages=315–318 |year=2017 |pmid=28030659 |doi=10.1001/jamadermatol.2016.4676 |url=}}</ref>
+*** Preferred treatment(1): [[Rituximab]]
+**: '''Note:''' Used is severe cases not improved by other medications.
 ==References==
 {{reflist|2}}
+{{WH}}
+{{WS}}
 [[Category:Gastroenterology]]
-[[Category:Primary care]]
 [[Category:Rheumatology]]
 [[Category:Autoimmune diseases]]
-[[Category:Gastroenterology]]
 [[Category:Genetic disorders]]
 [[Category:Malnutrition]]
 [[Category:Pediatrics]]
 [[Category:Dermatology]]
-[[Category:Primary care]]
 [[Category:Up-To-Date]]
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