Celiac disease medical therapy

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

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

• Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
• Pharmacologic medical therapies for celiac disease include gluten-free diet.
• Patient should be referred to a dietitian once the diagnosis of celiac disease is made.
• Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

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 Gluten free diet; 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)
        • Wheat starch

        Note: The 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
    • 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 coeliac 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.

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.

• 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 Immunosupressive 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