A Clinical Update

Nonceliac Gluten Sensitivity—Is it Really the Gluten?

Bernadette Capili, PhD, NP-C; Michelle Chang, MS; Joyce K. Anastasi, PhD, DrNP

Journal for Nurse Practitioners. 2014;10(9):666-673.

Diagnostic Testing for CD

For CD, serum IgA endomysial antibodies (EMA) and tissue transglutaminase (tTG) antibody testing have the highest diagnostic accuracy.^[17] Immunoglobulin A (IgA) anti-tTG antibody testing is the preferred method for detection of CD in individuals over the age of 2 years.^[5] Positive celiac serologic testing on a gluten-containing diet and endoscopy with duodenal biopsy with villous atrophy consistent with CD will confirm the diagnosis of CD.^[5] For NPs, it is important to emphasize to patients that they must be ingesting gluten to test for CD. If a patient has started a gluten-free diet on their own for several weeks before testing, then the tests to diagnose CD may be negative and unreliable. If CD is still suspected, a gluten challenge may be done and tests repeated. For CD, the classic gluten challenge has been to consume at least 10 g of gluten (the equivalent of 4 slices of bread) per day for 6 to 8 weeks,^[5,18] but a recent CD study suggested the gluten challenge may be shortened to 2 weeks with doses of 3 grams (1 slice of bread) per day.^[19]

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Abstract and Introduction
What is NCGS?
Differences Between CD and NCGS
Diagnostic Testing for CD
Diagnostic Testing for NCGS
Nonceliac Gluten or Wheat Sensitivity: Is it the Gluten or the Wheat?
Wheat Allergy
Clinical Management
References
Sidebar

Table 1. Signs and Symptoms of Gluten/Wheat-related Disorders
	Nonceliac "Gluten Sensitivity"	Celiac Disease	Wheat Allergy
Gastrointestinal	Abdominal pain Bloating Nausea Diarrhea Constipation	Abdominal pain Diarrhea Constipation Weight loss Vomiting Pale, foul-smelling, or fatty stool	Abdominal pain Abdominal cramps Vomiting Diarrhea Nausea
Non-gastrointestinal	Headache Fatigue Brain fog or "foggy mind" Joint and muscle pain Numbness in the hands and feet Depression Eczema and/or rash	Unexplained iron-deficiency anemia Headache Fatigue Bone or joint pain Brain fog Tingling or numbness in hands and feet Ataxia Dermatitis herpetiformis Osteoporosis or bone loss Depression Anxiety Seizures Missed menstrual periods Infertility or recurrent miscarriage Dental enamel defects Aphthous stomatitis	Dizziness or light-headedness Difficulty breathing, Swelling, itching, irritation of the mouth or throat Eczema Hives Asthma Rhinitis Itchiness Angioedema Anaphylaxis Headache

Data from National Institute of Diabetes and Digestive and Kidney Diseases,⁶ Sapone et al,⁸ National Institute of Allergy and Infectious Diseases,⁴⁰ and Scibilia et al.⁴⁹

Table 2. Overlooked Foods and Other Products That May Contain Gluten and/or Wheat
Foods	Condiments/sauces/gravies	Beverages	Others	Drugs^a
Wheat (in any form)^b Barley (in any form)^c Rye (in any form) Croutons Panko (breadcrumbs) Imitation bacon Imitation seafood, such as artificial crabmeat in sushi Batter, breading, coating mixes in fried fish, chicken wings Tortillas Soup bases—bouillon cubes, cream-based soups (flour as a thickener) Processed luncheon meats Energy and snack bars Pickles (some pickling process may include malt vinegar) Candy, such as licorice and malted milk balls	Barbecue sauce Soy sauce Marinades Salad dressing Brown rice syrup	Nondistilledgluten-containinggrain (wheat, barley, rye, malt), alcoholicbeverages andvinegars, such asbeers, ales, lagers, and maltbeverages Flavored coffee/teas/tea mixes (flavorings may contain malt/barley)	Craft supplies, such as play dough, paper mache, finger paints (may contain wheat flour) Communion wafers Lip gloss/lip balms/lipsticks ingredients: Hydrolyzed wheat protein Hydrolyzed wheat starch Hydrolyzed wheat gluten Triticum vulgare Wheat germ oil Wheat germ extract Oat kernel flour Avena sativa Barley extract Hordeum vulgare Secale cereal	Fillers or excipients: Wheat Modified starch (source not specified) Pregelatinized starch (source not specified) Pregelatinized modified starch (source not specified) Dextrates (source not specified) Dextrimaltose (when barley malt is used) Caramel coloring (when barley malt is used) Dextrin (source not specified, but usually by corn or potato)

^aDrugs and over-the-counter medications, including vitamin, mineral, and herbal supplements.
^bEinkorn, emmer, bran, durum, graham, wheatberries, farro, kamut, matzoh, semolina, spelt, bulgur, couscous, farina, triticale, orzo, udon, seitan, spelt.
^cBrewer's yeast, malt, malt extract/syrup/flavoring, malt vinegar. Data from American Celiac Disease Alliance,⁵⁰ Celiac Disease Foundation,⁵¹ American Society of Health Pharmacists,⁵² and Thompson and Grace.⁵³