Early Intervention for Asymptomatic Celiac Disease Reaps Benefits

Caroline Helwick

May 11, 2011

May 11, 2011 (Chicago, Illinois) — Serological screening of persons at risk for celiac disease, but who are still asymptomatic, can detect the disease and prompt an effective treatment intervention, according to a study from Finland presented here at Digestive Disease Week (DDW) 2011.

"We found that early diagnosis and treatment of celiac disease is beneficial in most of the screen-detected asymptomatic patients. Most of our patients were willing to continue on a gluten-free diet [GFD]. We therefore believe that screening of at-risk groups is justified," said lead author Kalle Kurppa, MD, from the University of Tampere in Finland.

At a plenary session here at DDW, Dr. Kurppa noted that approximately 2% of the population has celiac disease, although 90% of affected persons are never formally diagnosed.

"Screening for celiac disease is problematic, and treatment is difficult. It is also unclear whether early diagnosis and treatment of screen-detected celiac disease is truly beneficial," Dr. Kurppa said.

The study aimed to determine the benefit of intervening with a GFD in asymptomatic adults testing positive on endomysial antibody (EmA) serological screening.

Investigators identified 3031 relatives of patients with celiac disease, of whom 148 were EmA-positive and 40 agreed to be randomly assigned to remain on their usual diet (n = 20) or start a GFD (n = 20). In addition to EmA testing, they were tested for transglutaminase 2 antibodies and were surveyed on the Gastrointestinal Symptoms Rating Scale and Psychological General Well-Being instrument. Laboratory parameters, celiac-specific genetics, bone mineral density, and body composition were also assessed, as was small bowel mucosal morphology and inflammation.

Patients were evaluated at baseline and 1 year later, at which time 18 of 20 control patients chose to begin the GFD as well.

Improvements Observed in All Parameters

The GFD group demonstrated mucosal healing (changes in the villous height/crypt depth ratio); the control patients did not (P < .001).

Senior investigator Katri Kaukinen, MD, PhD, elaborated on this outcome at a press briefing. "After 1 year, those on a normal gluten diet had persistence or evening a worsening of mucosal lesions, but those who started on a GFD showed recovery of the mucosa. The difference was really significant at 1 year."

The GFD group also had significant drops in EmA titers (P < .001) and transglutaminase 2 antibody titers (P < .001) from baseline, as well as improvements in symptoms (P < .001) and quality of life (P < .001), although control patients did not.

In the control patients who initiated the GFD diet, changes of similar magnitude were observed in all these outcomes, with the exception of quality of life after 1 year. Mean laboratory parameters, body mass index, and bone mineral density were within normal ranges at baseline, and no significant changes were observed with the intervention. Levels of folate and vitamin B12, however, improved significantly with the diet.

Attitudes toward screening and the dietary intervention were positive, Dr. Kurppa added. Twenty-seven patients (67%) reported being adherent to the GFD, 10 patients (25%) reported only a few lapses, and only 3 patients (8%) reported frequent lack of adherence.

Thirty-four patients (85%) were willing to continue on a GFD in the future.

"The diet was considered 'easy' by 5%, 'quite easy' by 67%, and 'difficult' by only 13% of patients," he said; 15% were "uncertain." More than half the patients experienced the serological screening as positive or very positive, and none felt it was a negative experience.

At the press briefing, Dr. Kaukinen noted that although patients initially reported few — if any — symptoms, after being on the GFD they reported they felt much better.

"We don't know why celiac patients have these different clinical phenotypes, why some get severe symptoms and others do not," she commented. "But one explanation is that people adapt to minor symptoms, and it is only after recovery that they realize they were symptomatic. Some patients told us they felt totally different on the diet."

Dr. Kaukinen said the reason to identify persons early is to prevent worsening of symptoms, vitamin deficiencies, and possibly a loss in bone mineral density. "If we see early signs of disease, why should we wait when we can do something for them now?" she asked.

After the presentation, a listener from the audience questioned whether the results "could be trusted," given the fact that the study was not blinded and that the intervention group was aware of their treatment. Another questioned whether the population might be biased toward acceptance of the diet, based on observing family members manage their disease.

"It is not possible to do a blinded study with a GFD, and there is certainly the potential for bias," Dr. Kurppa acknowledged, "but still the results are clear, and I think we can trust them, although we do need longer follow-up to see if the benefits persist. It's also possible that patients with family members would be willing to accept the diet, and therefore we probably cannot generalize our findings to all persons with celiac disease."

Mark Delegge, MD, director of the Digestive Disease Center at the Medical University of South Carolina in Charleston, responded to the findings by telling Medscape Medical News he believes screening for celiac disease may be warranted in persons with symptoms indicative of irritable bowel syndrome. However, he added, "I would not screen all patients. I might, however, broaden my screening beyond persons with severe classic celiac disease symptoms."

Dr. Kurppa, Dr. Kaukinen and Dr. Delegge have disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2011: Abstract 620. Presented May 9, 2011.

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