Celiac disease medical therapy

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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

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 steroids, azathioprine, cyclosporin, and monoclonal antibodies.

Medical Therapy

• Dietary modification is the preferred theray for celiac disease, which includes gluten-free diet.
• Patients with a confirmed diagnosis of celiac disease should be referred to a dietitian.

Celiac Disease

• 1 Dietary modification
  • 1.1 Gluten-free diet (GFD)
    • 1.1.1 Storage proteins not allowed

      • Wheat
      • Rye
      • Barley
      • Spelt
      • Kamut
      • Emmer wheat
      • Einkorn wheat
      • Green spelt

    • 1.1.2 Storage proteins 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)
        • 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
    • 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.

Refractory disease

A minority of celiac disease patients suffer from refractory disease, which means that they do not improve with 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 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 for 12 weeks