Managing Gluten-Related Disorders and "Gaps" in the Gluten-Free Diet - InSight+

Managing Gluten-Related Disorders and “Gaps” in the Gluten-Free Diet – InSight+

The mainstay of treatment for celiac disease and other gluten-related disorders is adherence to a gluten-free diet (GFD)(1).

GFD remains the only effective means to ensure remission of symptoms, normalization of serum autoantibodies indicative of disease activity, and healing of the histological architecture of the gut. However, due to the ubiquitous nature of gluten(2,3,4)Inadvertent ingestion of gluten-containing foods is a common problem that adversely affects many aspects of GFD patients’ lives.

A GFD is the only treatment available for these conditions, but is it also a problem?

Several studies show that up to 70-90% of celiac patients following a GFD regularly consume potentially harmful amounts of gluten, generally unintentionally.(5,6,7,8,9). Not surprisingly, most patients diagnosed with celiac disease have persistent gastrointestinal symptoms such as bloating, cramping, diarrhea, and extraintestinal symptoms such as gluten ataxia, neuropathy, encephalopathy, fatigue, depression, and anxiety, despite best efforts to adhere to a strict GFD(10,11,12,13).

GFD treatment is complex. Requires complete removal of gluten. However, even trace amounts of gluten contamination can cause intestinal damage in celiac patients and persistent symptoms in all gluten-related disorders. Even 10 mg of gluten can trigger an autoimmune reaction in the most sensitive individuals(14).

Meals and meal preparations are social in nature. Most social events, family affairs and travel (leisure or otherwise) involve food. Most of the time, these foods are prepared by others and are considered a common cause of inadvertent gluten ingestion. Not surprisingly, the restrictive nature of the GFD can lead to social isolation and anxiety in some patients.

When prescribing a GFD, clinicians must be aware of the multifaceted impact it has on patients’ lifestyles and quality of life. Until alternative treatments are developed, it may be beneficial to consider patient education and tools to cover the “gaps” in an otherwise gluten-free diet.

What is enzyme therapy and is it effective?

Several therapies available and in development are designed to address the problem of inadvertent gluten ingestion. In particular, enzyme therapy involves the use of an enzyme capable of cleaving toxic and immunogenic peptides in gluten. By breaking down these peptides in vivo, Before it interacts with the intestinal lining, inflammation in gluten-related disorders and an autoimmune response in celiac patients that leads to symptoms including intestinal damage can be averted.

Australian technology (GluteGuard; Glutagen Pty Ltd, Melbourne, Australia) uses caricain, an enzyme found in latex Upload papaya a fruit that has been shown to be highly active in hydrolyzing toxic gluten peptides in vitro(15,16,17). Clinical studies evaluated the efficacy of enteric-coated tablets of caricaine in protecting against symptoms and histological damage in patients with celiac disease receiving 1 g daily of gluten for up to 42 days(18). All participants in this study were in clinical remission.

A study showed that caricaine supplementation was able to protect against gluten-induced symptoms (P < 0.01) and significantly better well-being (P < 0.01).

The study could not properly assess intestinal damage due to the majority of placebo subjects withdrawing from the study after developing severe symptoms before day 14. Despite this, a notable finding was that the duodenal histology of participants in the treatment group was not exacerbated despite significant (1 g/day) and prolonged (42 days) gluten exposure.

The second study(19) investigated the effectiveness of caricaine in patients with dermatitis herpetiformis, a skin condition common in celiac patients that is also triggered by gluten components. Patients were given 6 g of gluten per day for 14 days, with ten taking caricaine tablets and ten taking placebo. Those taking caricaine fared much better, with 81% being protected from growing areas of skin lesions (P = 0.02). A 71% reduction in the incidence of skin lesions and a 38% reduction in the incidence of unpleasant itching were observed in the treated group.

It should be noted that enzyme therapy using caricain is not a treatment or cure for any gluten-related disease or condition. Caricaine supplementation is only intended as an adjunct to a GFD to detoxify the small amounts of gluten that are inadvertently but routinely consumed.

Addressing the gluten-free diet gap in clinical practice

GPs should consider referring patients who do not fully respond to a gluten-free diet to a specialist dietitian who will support them in education, assess adherence to the diet and also possibly provide counseling to help navigate the complex social elements of following a GFD. A specialist psycho-gastroenterologist may also be considered for patients who show signs of depression, isolation and anxiety.

Caricaine enzyme therapy is worth considering. It offers valuable protection when patients eat out or in situations where their food may be contaminated with gluten. They support the post-marketing experience impressively.

Professor Finlay Macrae AO is Head of Colorectal Medicine and Genetics at the Royal Melbourne Hospital. He focuses primarily on inflammatory bowel disease (IBD) and familial bowel cancer and is actively involved in new advances in IBD through his research.

Conflict of interest: Chair of the Glutagen Medical Advisory Board. Lead researcher in clinical trials investigating Glutagen products.

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