Medication and Supplement Use in Celiac Disease

Ashley N. Johnson, PharmD, BCPS; Angela N. Skaff, BS, PharmD Candidate; Lauren Senesac, PharmD Candidate

Disclosures

US Pharmacist. 2014;39(12):44-48. 

In This Article

Management

Currently, no medications are available to manage symptoms or prevent small-intestinal damage associated with gluten ingestion in CD.[7] Management of this chronic condition relies solely on the permanent avoidance of gluten-containing foods and products, which may necessitate significant changes in lifestyle, since gluten is a ubiquitous component of food, beverages, medications, and supplements.[5,7]

Avoiding Gluten-containing Foods and Beverages

A working knowledge of common foods that contain gluten and how to inspect food labels to determine the presence of gluten-containing additives (e.g., emulsifiers and stabilizers) is essential for preventing symptoms and secondary complications of CD. Wheat, barley, and rye contain gluten and should be avoided. Buckwheat, corn, flax, potato, quinoa, rice, soybean, and tapioca flours are considered gluten-free and safe to consume. Consumption of pure oats in limited quantities is considered safe for most people with CD.[5,18] However, oats may be contaminated with gluten during the manufacturing process; therefore, they should be carefully introduced with ongoing monitoring of symptoms.[7] The ACG strongly recommends that CD patients be referred to a registered dietitian for nutritional counseling.[7] In addition to food products, individuals with CD should avoid alcoholic beverages containing gluten (i.e., most beers, ales, lagers, and malt vinegars, although some varieties are specifically marketed as gluten-free and are safe for consumption).[5] Distilled alcohol drinks and wine are safe to ingest.[5]

Avoiding Gluten-containing Medications, OTC Products, Supplements, and Vitamins

As previously mentioned, manufacturers of prescription or OTC medications are not required to disclose on the package labeling whether the product contains gluten. Consequently, it is important to investigate each orally ingested medication, supplement, and vitamin for the presence of any ingredients or excipients that may contain gluten. This often can be accomplished by evaluating the ingredient list, contacting the manufacturer, or utilizing a variety of other resources. Gluten can potentially be introduced and contaminate otherwise gluten-free products during the manufacturing process, although the likelihood is low.[6] Key points to consider are that even if a brand product is confirmed to be gluten-free, it cannot be assumed that the generic version is also gluten-free, and that if a product has a new formulation, appearance, or manufacturer, it is prudent to reassess it and confirm that it remains gluten-free.[6]

When evaluating the gluten content of prescription and OTC products, it should be remembered that gluten can be masked in an excipient. Starches used as excipients in pharmaceutical products are often derived from rice, potato, or tapioca, which are gluten-free. However, if the source of the starch is not explicitly stated, the excipients may contain gluten. Sources of excipients that contain gluten include barley, farina, kamut, rye, spelt, triticale, and wheat.[19,20] See Table 3 for a list of excipients that may contain gluten and should be investigated to determine the source of the starch.[6]

Excipients that are considered safe for consumption in individuals with gluten intolerance include sweeteners such as glucose, fructose, and corn syrups, as well as fillers, thickening agents, and polymers such as gums and cellulose derivatives.[5,6] Sugar alcohols such as mannitol and sorbitol, which commonly are used as sweeteners and bulking agents, are gluten-free, but if ingested in large quantities can cause gluten-like symptoms, such as diarrhea.[21] Barley-based brown rice syrup, wheat-based dextrin, and maltodextrin should be avoided.[5]

Additional Considerations

Other manifestations of CD include nutritional deficiencies and bone loss secondary to malabsorption. It is recommended that CD patients be assessed for nutritional deficiencies (vitamins A, D, E, and B12, carotene, copper, iron, folic acid, magnesium, selenium, and zinc) and receive supplementation, if needed.[7] Patients should be screened for osteopenia or osteoporosis and should be managed accordingly, if needed, to ensure that the recommended dietary allowance for calcium is being met.[7]

Prophylactic administration of the pneumococcal vaccine may be reasonable in this population, given that one-third of adults with CD have inadequate splenic function.[22] At this writing, the CDC has not provided any formal recommendations specifically for the use of the pneumococcal vaccine in CD.

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