COMMENTARY

Diet and a New Drug: A One-Two Punch Against Gluten?

Digestive Disease Week (DDW) 2018

William F. Balistreri, MD

Disclosures

August 01, 2018

The Real Challenge: Avoiding Gluten

Studies presented at this year's Digestive Disease Week addressed an ongoing challenge for patients with celiac disease (CD): adherence to a gluten-free diet.

Once a diagnosis of CD has been confirmed, strict avoidance of exposure to gluten is recommended. However, the challenge of adhering to a gluten-free diet is exacerbated by the fact that variable amounts of gluten contaminate "gluten-free foods" because of less than precise food production, processing, packaging, or preparation. In addition, labeling may be inexact. Inadvertent exposure to gluten also may be associated with exposure to nonfoodstuffs (eg, lipstick, toothpaste). As a result of contamination, patients may continue to have mucosal inflammation despite a gluten-free diet.

Whereas the amount of gluten is known for individual products, the degree of inadvertent exposure to gluten by persons with CD is unknown. Gluten immunogenic peptide (GIP) analysis, which allows direct and quantitative assessment of gluten exposure, has been shown to be of value in the diagnosis and clinical management of patients with nonresponsive or refractory CD.[1]

Silvester and colleagues[2] determined the amount of gluten ingested by highly motivated, educated patients with CD adhering to a gluten-free diet by measuring the levels of GIPs in food, urine, and stool and the relationship with gluten exposure and persistent villous atrophy or related symptoms. As part of the study, participants also saved "doggie bags" for analysis that contained a sample of any processed or cooked food consumed.

Gluten was detected in at least one sample from 86% of patients consuming a gluten-free diet. Overall, approximately 33% of food samples positive for GIPs contained > 20 ppm of GIPs, with some containing > 100 ppm of GIPs. The estimated amount of GIPs ingested ranged from 0.23 mg to > 40 mg per exposure.

These novel data confirm that strict gluten avoidance is difficult to achieve, even by those who are highly motivated and educated.

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