Treatment in Celiac
Total lifelong avoidance of gluten ingestion is the cornerstone treatment for patients with celiac disease (CD). Wheat, rye, and barley are the grains that contain toxic peptides. They should be eliminated as completely as possible, although daily intake doses larger than 10 mg are likely needed to cause mucosal reaction. GI symptoms in patients with symptomatic celiac disease who adhere to a gluten-free diet typically resolve within a few weeks; these patients experience the normalization of nutritional measures, improved growth in height and weight (with resultant normal stature), and normalization of hematological and biochemical parameters.
Furthermore, treatment with a gluten-free diet reverses the decrease in bone mineralization and the risk for fractures . Symptomatic children treated with a gluten-free also improve their sense of physical and psychological well being.
For a long time, oats were considered toxic as well, and their elimination from the diet had been recommended. However, over the past decade, a growing body of scientific evidence obtained from in vitro studies as well as from clinical investigations (particularly in adults but also, more recently, in children) suggests that oats are totally safe. Because of uncontrolled harvesting and milling procedures, as well as the possibility that lines of manufacturing used for wheat-based flours are also used in the preparation of oat-based foods, cross-contamination of oats with gluten is still a concern.
Lactose is often eliminated in the initial phases of dietary treatment as well. This is because lactase deficiency is thought to accompany the flat mucosa. However, most newly diagnosed patients with celiac disease are diagnosed in the absence of overt malabsorptive symptoms; in these circumstances, clinically significant lactose malabsorption or intolerance is rarely seen. Furthermore, even in cases with obvious malabsorption, the recovery of lactase activity is typically fast; thus, a lactose-free diet must be used on a short-term basis only, even in these individuals.
The American Dietetic Association (ADA) publishes guidelines for the dietary treatment of celiac disease. They are a reliable source of information for a gluten-free. However, because of the dynamics of this field, the diet requires ongoing collaboration between patients, health care providers, and dietitians.
Because of the protean nature of celiac disease, multiple consultations may be necessary. For example, consultations with an endocrine specialist should be arranged for patients who also have Hashimoto thyroiditis or type I diabetes mellitus, and a rheumatologist must be consulted for patients who have arthritis.
No additional restriction is necessary beyond that imposed by the patient’s fatigue. However, if a completely gluten-free diet is followed, celiac disease completely regresses, and individuals have a completely normal quality of life.
Complete elimination of gluten-containing grain products, which include wheat, rye, and barley, is essential to treatment. After an initial period of avoidance, oats might be reintroduced into the diet of patients with celiac disease. These patients should be monitored carefully for recurrent symptoms.
Corticosteroids can rapidly control severe symptoms of celiac disease (CD). They may also have a role in rare cases in which the patient has no response to diet; this condition is known as refractory celiac disease and occurs exclusively in adults (1-3% of total).
For celiac disease in children, steroids are almost never needed.
Some cases of refractory celiac disease (with all other forms of colitis and enteritis excluded) respond to parenteral corticosteroids, for reasons unknown. Exclude other etiologies of failure to thrive, especially in children, because systemic steroids can pose risk to growth. Sodium succinate salt formulation may be administered IV or IM.
- The primary treatment of celiac sprue is dietary.
- Removal of gluten from the diet is essential. Complete avoidance of gluten-containing grain products is relatively difficult for patients to achieve and maintain because certain products, such as wheat flour, are virtually ubiquitous in the American diet.
- Careful and extensive indoctrination of the patient by the physician and the dietitian is often necessary to achieve full compliance.
- A small percentage of patients with celiac sprue fail to respond to a gluten-free diet. In some patients who are refractory, corticosteroids might be helpful.
- In patients who fail to respond to corticosteroids, other comorbid conditions, such as lymphomas of the small intestine, have to be ruled out.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Corticosteroids might be indicated in patients with refractory celiac sprue.
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. These agents modify the body’s immune response to diverse stimuli.
Can be used in patients with refractory celiac sprue. Might decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
30-40 mg/d PO; taper off completely in 6-8 wk
1 mg/kg/d PO; not to exceed 30 mg/d; taper off completely in 6-8 wk