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Determination of gluten consumption in celiac disease patients on a gluten-free diet


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Background: Celiac disease (CD) patients adhering to a gluten-free diet (GFD) are exposed frequently to low levels of gluten that contribute to symptoms and persistent intestinal histologic damage. Objective: We analyzed prior clinical data to determine how much gluten is accidentally consumed while on a GFD. The aim was to understand the range of gluten consumption for a wide distribution of CD patients. Design: A meta-analysis was conducted on data from 2 different clinical programs: 1) measurements of gluten in stool and urine in CD and non-CD populations; and 2) analysis of data from trials for the investigational therapeutic latiglutenase. The stool and urine studies included controlled gluten challenges. A calibration factor was applied that allowed normal ingestion of gluten to be computed from the urine and stool measurements. From the latiglutenase trial data, a determination of gluten consumption was made by estimating how much gluten was eliminated from patients' diets due to a trial effect that led to improved histology even in the placebo group. Results: The average inadvertent exposure to gluten by CD individuals on a GFD was estimated to be ∼150-400 (mean) and ∼100-150 (median) mg/d using the stool test and ∼300-400 (mean) and ∼150 (median) mg/d using the urine test. The analyses of the latiglutenase data for CD individuals with moderate to severe symptoms indicate that patients ingested significantly >200 mg/d of gluten. Conclusions: These surrogate biomarkers of gluten ingestion indicate that many individuals following a GFD regularly consume sufficient gluten to trigger symptoms and perpetuate intestinal histologic damage.
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Determination of gluten consumption in celiac disease patients on a
gluten-free diet
Jack A Syage,1Ciarán P Kelly,2Matthew A Dickason,1Angel Cebolla Ramirez,3Francisco Leon,3Remedios Dominguez,3
and Jennifer A Sealey-Voyksner1
1ImmunogenX, Newport Beach, CA; 2Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA; and 3Biomedal, Seville, Spain
Background: Celiac disease (CD) patients adhering to a gluten-
free diet (GFD) are exposed frequently to low levels of gluten
that contribute to symptoms and persistent intestinal histologic
Objective: We analyzed prior clinical data to determine how much
gluten is accidentally consumed while on a GFD. The aim was to
understand the range of gluten consumption for a wide distribution
of CD patients.
Design: A meta-analysis was conducted on data from 2 different clin-
ical programs: 1) measurements of gluten in stool and urine in CD
and non-CD populations; and 2) analysis of data from trials for the
investigational therapeutic latiglutenase. The stool and urine studies
included controlled gluten challenges. A calibration factor was ap-
plied that allowed normal ingestion of gluten to be computed from
the urine and stool measurements. From the latiglutenase trial data,
a determination of gluten consumption was made by estimating how
much gluten was eliminated from patients’ diets due to a trial effect
that led to improved histology even in the placebo group.
Results: The average inadvertent exposure to gluten by CD individ-
uals on a GFD was estimated to be 150–400 (mean) and 100–150
(median) mg/d using the stool test and 300–400 (mean) and 150
(median) mg/d using the urine test. The analyses of the latiglutenase
data for CD individuals with moderate to severe symptoms indicate
that patients ingested signicantly >200 mg/d of gluten.
Conclusions: These surrogate biomarkers of gluten ingestion indi-
cate that many individuals following a GFD regularly consume suf-
cient gluten to trigger symptoms and perpetuate intestinal histologic
damage. Am J Clin Nutr 2018;107:201–207.
Keywords: celiac disease, gluten exposure, gluten-free diet
Celiac disease (CD) is the most common autoimmune gas-
trointestinal disease, affecting 1% of the world population
(13). There are currently no US Food and Drug Administration
(FDA)–approved treatments, other than a gluten-free diet (GFD),
which is exceedingly difcult to maintain. The average Western
diet contains 5–15 g gluten/d (4). Gluten ingestion as low as
50 mg/d can be harmful to some celiac patients (5). The elim-
ination of 99% of gluten from a diet may still be insufcient
to avoid symptoms and histologic damage. The FDA has estab-
lished a guideline that foods labeled gluten free must contain <20
ppm gluten (6). However, there are difculties with currently ap-
proved analytical methods for the detection and quantication of
gluten in certain foods (e.g., fermented and hydrolyzed foods)
There is an unmet need to protect against unintended gluten
ingestion, particularly since persistent uncontrolled gluten expo-
sure is known to lead to life-long health issues and comorbidities
such as anemia, malnutrition, and lymphoma (10). As such, in-
vestigational drugs in clinical development are generally intended
to be used as an adjunct to a GFD (1114).
Despite the obvious need to protect CD patients against ex-
posure to gluten consumption, there is surprisingly very little
known about the quantity of gluten that is accidently consumed
episodically and continually for those on a GFD. Much has been
written about GFDs and the complexities, difculties, and chal-
lenges associated with maintaining strict adherence across so-
cial and demographic groups and behaviors (1517). However,
we are unaware of any studies that attempt to analytically de-
termine the actual quantity of gluten that is consumed while on
In this work, we performed a meta-analysis based on data from
clinical studies that provided key information needed to deter-
mine the amount of gluten that CD patients consume while at-
tempting to follow a GFD.
Supported by ImmunogenX.
ImmunogenX is a clinical-stage company developing the therapeutic drug
latiglutenase for treating celiac disease and also a minimally invasive drug
biomarker and blood test for monitoring the villous health of the small intes-
Address correspondence to JAS (e-mail:
Abbreviations: CD, celiac disease; FDA, Food and Drug Administration;
GFD, gluten-free diet; GIP, gluten immunogenic peptide; LOD, limit of de-
tection; Vh:Cd, villous height–to–crypt depth ratio.
Received August 14, 2017. Accepted for publication November 29, 2017.
First published online February 26, 2018; doi:
Am J Clin Nutr 2018;107:201–207. Printed in USA. © 2018 American Society for Nutrition. All rights reserved. 201
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FIGURE 1 Flow chart outlining the basis for selecting the studies used in the present analysis. CD, celiac disease; GFD, gluten-free diet; GIP, gluten
immunogenic peptide; Vh:Cd, villous height–to–crypt depth ratio.
The analysis was conducted combining clinical study re-
sults from the following sources: 1) measurements of gluten
in stool (NCT02711397 and NCT01478867) (18,19) and urine
(NCT02344758) (20) in non-CD and CD populations; and 2)
trial effect and symptom results for the study of latiglutenase
(NCT01255696) (13) and (NCT01917630) (21). These studies
(except for NCT01255696) focused primarily on CD patients
experiencing moderate to severe symptoms. The decision pro-
cess for selecting these studies is delineated by the ow chart in
Figure 1.
The measurements of gluten immunogenic peptides (GIPs) in
stool were performed using the ELISA Sandwich G12/G21 assay
(iVYLISA GIP, Biomedal SL). In urine, the results were deter-
mined by a quantitative lateral ow immunoassay (iVYCHECK
GIP Urine, Biomedal SL) using a lateral ow reader A1/G12
(iVYCHECK Reader, Biomedal SL). These measurements were
accompanied by controlled measurements of gluten exposure uti-
lizing a gluten challenge. A conversion factor (described be-
low) was determined that allowed the ingestion of gluten to be
computed. Gluten challenge measurements in stool showed that
gluten could be detected in stool for 4 d after a gluten chal-
lenge, indicating a sufciently long residence time (18,19), such
that a measured value of gluten in stool on any given day could
be a good indication of the peak gluten level and no additional
correction factor was needed. Gluten challenge measurements in
urine indicated a residence time of gluten in urine of about half
aday(20). Therefore, random measurements of gluten in urine
following unintended gluten ingestion would, on average, register
a value of about half that for the peak gluten level. The conver-
sion factor from GIP (expressed as ng/mL urine) to gluten inges-
tion (expressed as mg) was determined by 2 different methods: 1
was based on uncorrelated urine measurements following 42- and
84-mg gluten challenges, and the other was based on correlated
urine measurements to 500 mg gluten challenge. The former
method used a factor of 2 correction for the gluten residence
time. The details of how these conversion factors are computed
are given in the Results section.
In the second analysis we estimated the quantity of gluten that
was removed from the diets of patients in a Phase 2b latiglutenase
study (ALV003-1221) (21). The quantity of gluten eliminated
was determined by relating the improvement in villous height to
crypt depth ratio (Vh:Cd) for placebo patients to a standard t that
related deterioration of Vh:Cd to a continuous gluten intrusion,
as measured in a previous Phase 2a latiglutenase trial (ALV003-
1021) (13). Three cohort groups were given 1.5, 3.0, and 6.0 g of
gluten daily for 6 wk and experienced changes to their mucosa
(Vh:Cd) of 2.8–2.2, 2.6–1.5, and 2.8–1.1, respectively. A poly-
nomial t with a (0,0) intercept led to the following equation:
wg=46.5Vh:Cd268.2Vh:Cd (1)
where wgis the aggregate change in gluten weight to the diets
of the patients corresponding to the mucosal change (Vh:Cd).
The placebo as well as latiglutenase arms improved their mucosal
health due to the Hawthorne effect. From this improvement, one
can estimate the amount of gluten removed from their diets using
Equation 1. We further estimated the amount of gluten that re-
mained in their diets during the treatment phase of the trial, using
the trial effect improvement on symptoms (Results section). The
total gluten intake for these symptomatic patients before the trial
began can thus be estimated.
The statistical methods for the data used in this analysis are
published in the referenced manuscripts. The analysis in this
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Gluten consumption as measured in stool1
GIP concentration (μg/g stool) Gluten daily consumption (mg)
Cohort nMean Median SD Mean Median SD
Healthy non-CD
Adults 73 5.23 7.60 2.95 7802 11,699 4757
Adults (13 y) 74 0.22 0.13 0.40 244 141 488
Children (4–12 y) 79 0.32 0.11 0.88 387 118 1216
Children (0–3 y) 35 0.14 0.10 0.19 155 104 214
1Conversion factor for y=GIP (μg/g stool) to x=gluten daily consumption (mg) is y=0.0649x2+1.0461x. CD, celiac disease; GFD, gluten-free diet;
GIP, gluten immunogenic peptide.
study used standard polynomial ts and mean, median, and SD
calculations. The histogram plots were calculated using the his-
togram function in Excel and using a bin size to provide sufcient
resolution of the gluten distribution.
Measurements of gluten in stool and urine
In a series of studies, an estimate of gluten consumption by CD
patients following a GFD was determined by measuring GIPs in
stool (18,19) and urine (20). Population groups included healthy
non-CD patients and CD patients, each segmented as adults and
children. Measurements were also performed on healthy patients
under controlled gluten challenge conditions.
Table 1 shows results for stool samples. In this study a gluten
challenge was conducted for several days to equilibrate the gluten
content in stool. There was a 1- to 2-d induction period for gluten
to be detected in stool and similarly to be eliminated. The factor
for converting GIP concentration (in micrograms per gram) (x
variable) to gluten daily consumption (in milligrams) (yvariable)
was determined from measured mean values of 6.2 and 14.9 μg/g
in stool for daily gluten challenges of 9 and 30 g (18). Fitting
to a second-order polynomial going through the origin gave the
relation y=0.0649x2+1.0461x+0.0. The computed gluten
daily consumption for healthy non-CD adults was found to be
7.8 g (mean) and 11.7 g (median). Non-CD children were not
included in this study. This value is consistent with 5–15 g for
a typical gluten-containing diet (measured in Denmark) (4). This
analysis utilized the complete set of data [compared with the data
plotted in Figure 2 of Comino et al. (18)] for values above the
quantitation limit.
Both the mean and median values for each population group
are reported in Tabl e 1 due to the asymmetry in the distribution
of gluten ingestion. The computed daily gluten consumption for
CD adults (13 y old) on a GFD was 244 mg (mean) and 141 mg
(median), for older children (4–12 y old) it was 387 mg (mean)
and 118 mg (median), and for younger children (0–3 y old) it was
155 mg (mean) and 104 mg (median). These values must be qual-
ied in terms of accuracy as more than half of these individuals
recorded GIP (micrograms per gram) values below the limit of
quantitation (LOQ =0.16 μg GIP/g stool sample), computing to
169 mg gluten consumed daily (LOD =0.06 μg/g correspond-
ingto63mg)(19). As an example, for the 13 y old patients,
45 of 74 measured below the LOQ, which computes to 39%
averaging >169 mg gluten consumed daily. For children 0–3 and
4–12 y old this gure is 14% and 28%, showing a trend toward
increased gluten consumption with age.
Table 2 summarizes the results of urine samples, an indepen-
dent study from the stool results. Two methods were used to
estimate the conversion factor from GIP concentration in urine
to daily gluten consumption. The rst made use of the origi-
nal data from Moreno et al. (20) where the LOD was 3.5 ng
GIP/mL and gluten challenges of 42 and 84 mg (revised from
originally reported values of 25 and 50 mg) were mostly unde-
tected and detected, respectively. We therefore estimate the LOD
to correspond to the average of these gluten ingestions, giving
63 mg. The collection of the urine was uncorrelated with the
gluten consumption and a factor of 0.5 was introduced, reecting
the 0.5-d residence time during which gluten remains in urine
(essentially the full width, half height of the peak concentration)
(20). This led to a conversion factor for gluten daily consump-
tion (in milligrams) per GIP concentration (expressed as ng/mL
urine) measured of 63/(3.5 ×0.5) =36. A subsequent gluten
challenge study gave 18 patients 500 mg of gluten on 2 subse-
quent days (at dinner time) and then collected urine samples at
3 specic times during the following day (to be published). The
LOD was 2.2 ng GIP/mL. These unpublished results (A Cebolla
and R Dominguez) indicate a conversion factor of 50 (similar to
above), except the 0.5 factor was not necessary because the urine
measurement was at a xed time after ingestion. This value is
consistent with the previous factor and is the value that we use
in the current analysis as we believe these are more accurate data
and remove the need for the 0.5 urine residence time assumption.
We found that the computed daily gluten consumption for
healthy non-CD individuals was 5.7 g (mean) and 4.3 g (median)
for adults and 4.4 g (mean) and 0.74 g (median) for children.
This is lower than the 5–15 g of gluten (cited above) for a typical
gluten-containing diet and lower than the measurements in stool
(above). This may reect an upper limit or saturation level for the
ELISA assay. The computed daily gluten consumption for CD
individuals on a GFD was 363 mg (mean) and 158 mg (median)
for adults and 316 mg (mean) and 149 mg (median) for chil-
dren. Of note, similar to the stool results above, more than half of
these individuals recorded GIP (expressed as ng/mL) values be-
low the LOD (<188 mg gluten). Therefore, we assigned values
that linearly decremented from the LOD value to zero. We be-
lieve this is a more realistic assumption than assigning values of
zero as it is more reective of the extrapolation of values above
the LOD. By comparison, if these values are assigned zero, then
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FIGURE 2 Histogram plots of the distribution of gluten consumption in the different population groups as measured by GIP in stool. Dotted lines represent
demarcations for patients (in percentages) with greater-than-indicated gluten consumption. CD, celiac disease; GIP, gluten immunogenic peptide.
for adults the mean decreases from 363 to 319 mg, not a marked
We evaluated the distribution of gluten ingestion for the dif-
ferent CD and non-CD population groups. The stool measure-
ments are presented in Figure 2. For the non-CD adults (healthy
controls), there is a large spike in the distributions for gluten
consumption of >7 g, which corresponds to the upper signal sat-
uration limit. This corresponds to 58% of the population consum-
ing >7 g gluten/d. For children (0–3 and 4–12 y old) and adult
(13 y old) CD populations on a GFD, the gluten consumption
is considerably less, but consumption is not insignicant; adult
consumption of gluten of >300 mg/d occurs 18% of the time as
seen in Figure 2.
Figure 3 shows histogram plots for the distribution of test
subjects for the urine measurements. These results show that
the large majority of non-CD subjects consume <10 g gluten/d
Gluten consumption as measured in urine1
GIP concentration (ng/mL urine) Gluten daily consumption (mg)
Cohort nMean Median SD Mean Median SD
Healthy non-CD
Adults 42 113.2 85.3 112.1 5658 4264 5605
Children 34 87.9 14.8 117.0 4395 740 5848
Adults 27 7.3 3.2 12.7 363 158 634
Children 31 6.3 3.0 7.1 316 149 354
1Conversion factor for GIP (ng/mL urine) to gluten daily consumption (mg): 50. CD, celiac disease; GFD, gluten-free diet; GIP, gluten immunogenic
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FIGURE 3 Histogram plots of the distribution of gluten consumption in the different population groups as measured by GIP in urine. Dotted lines represent
demarcations for patients (in percentages) with greater-than-indicated gluten consumption. CD, celiac disease; GIP, gluten immunogenic peptide.
(a low value for a gluten-containing diet). The CD subjects obvi-
ously consume considerably less gluten on a daily basis, and these
data show 30% of adults and 32% of children consume >300 mg
gluten/d which is greater than, but consistent with, the results in
Figure 2 for the stool analysis.
Calculations based on the latiglutenase clinical trials
The Phase 2b ALV003-1221 trial was a real-world study where
patients were instructed to continue their GFD, but not to change
their normal dietary behavior. Over the 12-wk trial period, pa-
tients, on average, improved their GFD and mucosal health as
measured by their Vh:Cd. Figure 4 shows that the improvement
was similar for seropositive and seronegative subjects (mean
Vh:Cd 0.28) and for a small group of patients who contin-
ued on for a total of 24 wk the improvement increased further
(mean Vh:Cd 0.41). If we input 0.28 for Vh:Cd in Equation
1,weobtainwgof –15.4 g over the 12-wk treatment period,
which computes to a mean of 184 mg/d of gluten removed from
individual’s normal GFDs. Of note, Equation 1, which was de-
rived from added gluten to the diet, is not symmetric for positive
and negative values of wg.Ifwemakeitsymmetric,thenwe
obtain wgof –22.7 g or 271 mg/d. The former calculation as-
sumes that mucosal damage occurs more quickly or more exten-
sively than recovery; the latter calculation assumes they are the
same. There is no conclusive understanding of these phenomena,
and therefore we treat them as boundary conditions and use the
average of 228 mg/d for gluten elimination. This determination is
limited by the assumption that cumulative change in Vh:Cd from
total exposures over 6 wk of gluten challenge is similar to the
same exposure (or removal of gluten) over 12 wk.
The above conditional calculation is based on objective mea-
sures that clearly show that trial-bound patients signicantly re-
duced gluten from their diets and sets a lower limit on the amount
of gluten typically consumed in their normal GFDs. More dif-
cult is an estimate of the gluten consumption that remained in
their diets during the treatment period. There was clearly contin-
ued gluten intake as the trial revealed a statistically and clinically
signicant symptom improvement with the drug from baseline
relative to placebo of the order of 30–50% (for seropositive pa-
tients) for abdominal pain, bloating, tiredness, and constipation
(14). Any further effort to estimate the total gluten consumption
in this population of moderately to severely symptomatic patients
would invoke unjustiable assumptions so we instead leave this
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FIGURE 4 Vh:Cd for the placebo patients evidencing the trial effect in the Phase 2b trial. Patient numbers are: seropositive: n=54 (12 wk), n=12
(24 wk); seronegative: n=68 (12 wk), n=18 (24 wk). Seropositive patients are dened as patients registering a positive titer for either of anti-TG2 IgA, DGP
IgA, or DGP IgG. Delta, change in villous height–to–crypt depth for patients; DGP, deamidated gliaden peptide; PT, patient; TG2, tissue transglutaminase 2;
Vh:Cd, villous height–to–crypt depth; , change.
analysis with the knowledge that the amount is >228 mg/d by a
factor of 1/(1 – f)wherefis the fraction of gluten that was elimi-
nated from the diet due to the trial effect. By way of example, if
f=50%, then the implied pretrial gluten consumption would be
456 mg/d.
Gluten is ubiquitous, and continued exposure leads to persis-
tent histologic injury and episodic symptom distress in CD pa-
tients following a GFD. The GFD is vulnerable to gluten expo-
sure and it is hoped that these results will inform CD patients of
the need to re-evaluate their diets under the guidance of a clini-
cian or dietician and provide a guide for drug development for
this autoimmune disease, for which no effective drug therapy
Adult CD patients evidently consume, on average, potentially
unsafe levels of gluten while on a GFD (Tables 1 and 2). Mean
daily consumptions for adults were determined to be 244 mg
(stool analysis), 363 mg (urine analysis) and >228 mg (ALV003-
1221 trial analysis), with the latter value likely to be greater than
the former values. There is a general consistency in these analy-
ses and the potentially higher value for the latter case may reect
that this trial enrolled a more symptomatic CD population. The
fact that the placebo patients improved histologically in a 12-wk
trial due to a trial effect substantiates that they were consuming
signicant amounts of gluten before the trial. The stool and urine
analyses were also conducted on a population of children, and al-
though they generally consumed less than adults, the mean gluten
consumption may still be regarded as above the recommended
level of gluten ingestion for patients with CD (Tables 1 and 2and
Figures 2 and 3).
It should be noted that there is considerable variation in GIP
concentration in stool and urine that may impact the accuracy of
these analyses. A single ingestion of 0.5 g gluten showed a GIP
concentration in the rst urine in the morning that varied from
undetectable (only 1 out of 18 patients) to 41.9 ng/mL. Differ-
ences in GIP concentration in stool of volunteers ingesting the
same amount of gluten (9 or 30 g) were found (18). Variation of
excreted GIP from identical gluten intake could be due to the in-
teraction with other ingested food, the time from gluten ingestion,
the glutenase activity of the microbiome, the intestinal motility,
differential amount of digestive juices and enzymes, etc. In urine,
the variation may also be affected by the amount of ingested wa-
ter and the leakiness of the intestine. The differential modication
of the GIP by deamidation by transglutaminase might also con-
tribute to the variability of the results for single gluten ingestion.
There is, however, signicant correlation between the amount of
gluten ingested and the gluten excreted by either stool or urine,
and the sample sizes are sufciently large to statistically average
over these variabilities. However, it should be recognized that the
stool and urine tests are relatively new and the methods continue
to be improved.
Distribution plots for the frequency of occurrence at various
gluten ingestion levels showed that although many, if not most,
CD patients are able to control their gluten intake reasonably well,
others cannot. These analyses were not able to distinguish be-
tween individuals who are diligent or not diligent at maintaining
their GFD. For example, a low value may reect a diligent per-
son who consistently consumes a little gluten, or a less diligent
person who happened to consume a little gluten on the day of
the measurement. Regardless, the frequent measurement of high
gluten consumption indicates that a reasonable fraction of the
CD population have difculty controlling their GFD. Data from
Figures 2 and 3show that depending on the subclass of CD pa-
tients, anywhere from 3% to 19% of patients consume >600 mg
gluten on a daily basis. The ALV003-1221 trial data suggests that
individuals on a GFD cannot avoid accidental gluten intrusions
and these small amounts are sufcient to trigger severe symp-
tomatic responses and may contribute to histologic damage.
We thank Chaitan Khosla for encouraging us and reviewing this work and
Philip Lavin for valuable assistance on the statistical analysis.
The authors’ responsibilities were as follows: JAS and ACR: designed the
research; ACR, RD, FL, and JAS: conducted the research and provided es-
sential materials; JAS, CPK, and JAS-V: analyzed the data; JAS, CPK, and
MAD: wrote the paper: JAS, CPK, and ACR: had primary responsibility for
nal content; and all authors: read and approved the nal manuscript. JAS,
MAD, and JAS-V own stock in ImmunogenX; CPK has received research
support from Aptalis and has served on advisory boards of ImmunogenX,
Celimmune, Cour Pharmaceuticals, Innovate, and Takeda Pharmaceuticals;
ACR and FL own stock in Biomedal, Seville, Spain and Celimmune LLC.
The remaining author had no conicts of interest to declare.
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... This approach was chosen, since the innate immunitystimulating activity of ATI proteins is dose-dependent and a largely (>95%) "gluten"-reduced diet, which is relatively easy to maintain compared to a strict GFD, would cause no relevant immune activation in our (non-celiac) PSC patients. 32 However, per convention, we are using the term "gluten-free diet" (GFD) throughout the present work. ...
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Background Primary sclerosing cholangitis (PSC) is a progressive bile duct disease associated with inflammatory bowel disease (PSC‐IBD). Aim To investigate whether patients with PSC‐IBD benefit from a gluten‐free and amylase trypsin inhibitor (ATI)‐free diet (GFD). Methods We performed a prospective clinical pilot study administering an eight‐week GFD. The primary outcomes were colonic inflammation assessed by proctosigmoidoscopy, and liver stiffness (surrogate for fibrosis, inflammation and cholestasis) measured by transient elastography before and after GFD. Amongst the secondary (exploratory) outcomes were colonic mucosal and serum cytokine/chemokine changes, the intestinal microbiome and transcriptome dynamics, and shifts in serum markers of hepatic fibrogenesis. Results Fifteen patientns with PSC‐IBD completed the study. The study did not meet its primary outcome: the endoscopic score and liver stiffness remained unchanged. However, the expression of pro‐inflammatory mucosal cytokines and chemokines such as IL6, IL8, CCL2, and TNFα was significantly down‐regulated. Two critical markers of liver fibrosis and matrix remodelling, thrombospondin‐2 and ‐4, decreased significantly. The microbiota composition changed slightly, including a decrease in the pathogen Romboutsia ilealis. The intestinal transcriptome indicated a gut barrier improvement. Pruritus, fatigue, overall well‐being, faecal calprotectin levels, and serum alkaline phosphatase did not change significantly. Conclusions This study did not demonstrate a clinical improvement with short‐term GFD in patients with PSC‐IBD. However, a gluten/ATI‐free diet may improve biomarkers of intestinal inflammation and barrier function in these patients with associated with changes in the enteric microbiota. Further investigation of the therapeutic potential of gluten‐free diets in PSC‐IBD is warranted.
... Since the poor diagnosis rates indicate that many instances with CD remain undetected or untreated, techniques for diagnosis testing has indeed been proposed in addition to the successful treatment of a gluten-free diet. Additional significant issues with screening, such as the ideal age to test, the need of recurrent screening, as well as the connection between serum tests with longterm results, persist in additional to the absence of a convincing cost-benefit analysis [3][4] . For better understand the development of celiac disease ISSN: 2583-4053 Volume-1 Issue-4 || October 2022 || PP. [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] ...
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A persistent, global, immunological illness called CD affects those who are genetically predisposed to it. Inside the average population, celiac disease is thought to affect 1% of people worldwide. Its incidence varies according to regional or racial differences. Due to improved medical understanding with awareness, as well as the widespread use of extremely sensitive or precise diagnostic tests for celiac disease, the incidence of celiac disease had considerably grown over the last thirty years. Even though there is more understanding or awareness regarding celiac disease, up to 95% of celiac sufferers still go untreated. The uneven nature of small intestinal mucosa alterations may result in false-negative small intestinal histopathology. Throughout Western Europe, one percent of people suffer with CD. The research of milder clinical traits or the use of serological testing has boosted the detection accuracy. Although the age of presentation varies, individuals often present during the fourth or sixth decades. Compared to juvenile instances, adult’s instances of CD are more prevalent, with individuals as old as 65 are now being identified or given diagnoses. It usually happens after adding gluten to the diet. There is a considerable change toward fewer patients presenting with mild dementia or as symptomatic adults identified during testing, however there is a tendency towards decreasing individuals who present with severe CD marked by diarrhoea.
... R5 and G12 antibodybased ELISAs are frequently used to detect the threshold quantity of gluten (>20 mg/kg). The R5 monoclonal antibody (mAb) strongly recognizes the most toxic fragments of gliadin as QQPFP, QQQFP, LQPFP, and QLPFP sequences [47]. The G12 is a highly sensitive mAb antibody against the α2-gliadin 33-mer toxic peptide of the gliadin [48]. ...
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Celiac Disease (CeD) is a chronic small intestinal immune-mediated enteropathy caused by the ingestion of dietary gluten proteins in genetically susceptible individuals. CeD is one of the most common autoimmune diseases, affecting around 1.4% of the population globally. To date, the only acceptable treatment for CeD is strict, lifelong adherence to a gluten-free diet (GFD). However, in some cases, GFD does not alter gluten-induced symptoms. In addition, strict adherence to a GFD reduces patients’ quality of life and is often a socio-economic burden. This narrative review offers an interdisciplinary overview of CeD pathomechanism and the limitations of GFD, focusing on current research on possible dietary interventions. It concentrates on the recent research on the degradation of gluten through enzymes, the modulation of the microbiome, and the different types of “biotics” strategies, from probiotics to the less explored “viromebiotics” as possible beneficial complementary interventions for CeD management. The final aim is to set the context for future research that may consider the role of gluten proteins and the microbiome in nutritional and non-pharmacological interventions for CeD beyond the sole use of the GFD.
... While a GFD can reduce symptoms and intestinal damage, the diet is neither easy nor readily achievable by many patients and further can be lacking in essential nutrients. 4,5 The pathological lesion of villous atrophy in the proximal epithelium of the small intestine is due to an immune response to wheat, rye, or barley. Low levels of gluten exposure can lead to ongoing inflammation that can increase the risk of complications including lymphoma, bowel cancer, osteoporosis, anemia, and malnutrition. ...
Background & Aims Gluten ingestion in celiac disease (CeD) patients can lead to gastrointestinal symptoms and small intestinal mucosal injury Methods This gluten-challenge (GC) Phase 2 trial was double-blind, placebo-controlled, and assessed the efficacy and safety of a 1,200 mg dose of IMGX003 in CeD patients exposed to 2 g of gluten per day for 6 weeks. The change in the ratio of villus height to crypt depth (Vh:Cd) was the primary endpoint. Secondary endpoints included densities of intraepithelial lymphocytes (IEL) and symptom severity. These endpoints were evaluated by ANCOVA. Additional endpoints included serology and gluten-immunogenic peptides (GIP) in urine Results Fifty (50) patients were randomized, and 43 patients completed (n=21 IMGX003, n=22 placebo). The mean ΔVh:Cd (primary endpoint) for IMGX003 vs. placebo was -0.04 vs. -0.35 (p = .057). The mean ΔIEL (secondary endpoint) for IMGX003 vs. placebo was 9.8 vs. 24.8 (p = .018). The mean change (worsening) in symptom severity (secondary endpoint) for IMGX003 vs. placebo was 0.22 vs. 1.63 (abdominal pain, p = .231), 0.96 vs. 3.29 (bloating, p = .204), and 0.02 vs. 3.20 (tiredness, p = .113). The 3 x 2-week trend-line significance for these symptoms, respectively, were p = .014, .030 and .002 Conclusion IMGX003 reduced gluten-induced intestinal mucosal damage and symptom severity. number NCT03585478.
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Celiac disease (CD) is a common autoimmune disease affecting around 1% of the population. It consists of an immune-mediated enteropathy, triggered by gluten exposure in susceptible patients. All patients with CD, irrespective of the presence of symptoms, must endure a lifelong gluten-free diet (GFD). This is not an easy task due to a lack of awareness of the gluten content in foods and the extensive incorporation of gluten in processed foods. Furthermore, a GFD imposes a sense of limitation and might be associated with decreased quality of life in CD patients. This results in gluten contamination in the diet of four out of five celiac patients adhering to a GFD. Furthermore, one in three adult patients will report persistent symptoms and two in three will not achieve full histological recovery when on a GFD. In recent years, there has been extensive research conducted in the quest to find the holy grail of pharmacological treatment for CD. This review will present a concise description of the current rationale and main clinical trials related to CD drug therapy.
Celiac disease (CD) is a systemic immune-mediated disorder characterized by a specific serological and histological profile triggered by gluten ingestion, which is given in genetically predisposed subjects. Heterogeneous clinical presentation is characteristic in CD, affecting any organ or tissue with gastrointestinal, extraintestinal, seronegative, or nonresponsive manifestations. CD diagnosis is based on several criteria, including genetic and serological tests, clinical symptoms and/or risk conditions, and duodenal biopsy. Currently, the available treatment for CD is a strict gluten-free diet (GFD) that essentially relies on the consumption of naturally gluten-free foods, such as animal-based products, fruits, vegetables, legumes, and nuts, as well as gluten-free dietary products that may not contain more than 20 mg of gluten per kg of food according to Codex Alimentarius. However, it is difficult to maintain a strict oral diet for life and at least one-third of patients with CD are exposed to gluten. Difficulties adhering to a GFD have led to new tools to monitor the correct adherence to GFD and alternative forms of treatment.
The major goal of this study is to describe and analyse numerical simulations based on Adams–Bashforth approach for fractal–fractional order autoimmune disease framework, to explore the function of viruses in the progression of autoimmune disease. Target cells, damaged cells, viruses, and effector immune cells are all studied using the Caputo fractal–fractional operator. Fixed point theorems are used to demonstrate the existence and uniqueness of the framework. The numerical technique is described utilizing Lagrange piecewise interpolation to achieve the numerical solution for different choices of the parameters. From a biological standpoint, the influence of different factors on the system and the numerical simulation results are explored. We compare the outcomes of distinct choices of the fractal and fractional order parameters to integer order results. The proposed model captures the relevant autoimmune disease behaviour with recurrent flare-ups in the typical instance, whereas mild symptoms are emphasized in various fractional and fractal–fractional scenarios.
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Many patients report symptoms after wheat ingestion experiencing a wide spectrum of clinical manifestations. Three possible diagnoses have been recognized: celiac disease (CD), wheat allergy (WA), and non-celiac (gluten) wheat sensitivity (NCGS/NCWS). CD is a chronic immune-mediated disease of the small bowel caused by exposure to dietary gluten in genetically predisposed individuals, with a prevalence of approximately 1%. It is characterized by mucosal inflammation and atrophy following exposure to gluten and improvement after gluten withdrawal. Food allergies are immunological responses to a food antigen. WA is the expression of an immunologically mediated process that can be immunoglobulin E (IgE) or non-IgE mediated; its many symptoms include urticaria/angioedema, asthma, rhinitis, and anaphylaxis. NCGS/NCWS is characterized by gastrointestinal and/or extra-intestinal symptoms after ingestion of gluten-containing food in subjects not affected by CD or WA. The aim of this review is to help physicians and nutritionists diagnose the cause of symptoms reported after wheat ingestion, thus avoiding patient frustration, inappropriate testing, and incorrect or missed diagnoses. An algorithm for the diagnostic approach in these patients is provided, to help to diagnose CD, WA, NCGS/NCWS or to identify possible functional disorders as the wheat-sensitive irritable bowel syndrome. A personalized approach, regular follow-up, and the help of a skilled healthcare professional are mandatory for patients with symptoms following wheat ingestion is provided. A gluten-free-diet is often recommended for patients with self-reported gluten/wheat-dependent symptoms; for patients with symptoms similar to those of functional diseases while there is evidence that a low-FODMAP diet could be the first option.
Alpha gliadin peptide induces damage and apoptosis of intestinal cells and aggravates pathology of celiac disease (CD) by inducing oxidative stress. Therefore, inhibition or alleviation of oxidative stress in CD may be an effective approach to the adjunctive treatment of CD. Black soybean peptides (BSPs) have been shown to inhibit oxidative stress and inflammation. The effect of BSPs on CD remains unknown. In this paper, the effect and mechanism of BSPs on the α-gliadin peptide (p31-43)-induced Caco-2 cytotoxicity were studied. We identified BSPs that alleviated the cytotoxicity of p31-43 in the CD cell model: Caco-2 cells were pre-treated with bioactive peptides for 3 hours before the addition of p31-43 for treatment for 24 hours, and then cells were collected for subsequent experiments. Our results show that p31-43 can significantly increase the ROS and MDA levels of Caco-2 cells, disrupt the glutathione redox cycle, reduce the activity of the antioxidant enzyme, and inhibit the activation of antioxidant signaling pathways. BSPs pretreatment can inhibit the increase of Keap1 protein induced by p31-43, activate antioxidant genes through Nrf2 protein, improve the activity of the antioxidant enzyme, alleviates glutathione redox cycle imbalance, promote the expression of GCLC or GCLM, and reduce oxidative damage. Graphical Abstract Pattern of BSPs against oxidative damage in CD cell mode
Proanthocyanidins have been shown to inhibit the signaling pathways related to oxidative stress and inflammation, also improved cell membrane integrity. The effect of peanut skin proanthocyanidins (PSPc) on CD remains unknown. In this paper, the effect and mechanism of PSPc on glial protein-induced Caco-2 cytotoxicity were studied. The results showed that PSPc may inhibit oxidative stress in DPG-induced CD model in vitro by regulating SIRT1/NRF2 pathway. By regulating SIRT1 and IκB signaling pathways, inhibit the phosphorylation of NF-κB and the deacetylation of NF-κB, inhibit inflammatory response, reduce release of inflammatory cytokines (IL-1β, IL-6, TNF-α), the cell survival rate was and the expression of TGM2 were improved, avoiding the damage of cell monolayer model. This experiment proved the prominent effect of PSPc on CD intervention. Studying the mechanism of PSPc in the treatment of CD injury will contribute to explore new therapies for CD which will be of great significance to supplement or replace gluten-free diets.
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Background and AimsCeliac disease (CD) is a widespread condition triggered by dietary gluten and treated with a lifelong gluten-free diet (GFD); however, inadvertent exposure to gluten can result in episodic symptoms. A previous trial of latiglutenase (; NCT01917630), an orally administered mixture of two recombinant gluten-specific proteases, was undertaken in symptomatic subjects with persistent injury. The primary endpoint for histologic improvement was not met, presumably due to a trial effect. In this post hoc analysis, we investigated the efficacy of latiglutenase for reducing symptoms in subgroups of the study participants based on their seropositivity. Methods The study involved symptomatic CD patients following a GFD for at least one year prior to randomization. Patients were treated for 12 weeks with latiglutenase or placebo. Of 398 completed patients, 173 (43%) were seropositive at baseline. Symptoms were recorded daily, and weekly symptom scores were compiled. p values were calculated by analysis of covariance. ResultsA statistically significant, dose-dependent reduction was detected in the severity and frequency of symptoms in seropositive but not seronegative patients. The severity of abdominal pain and bloating was reduced by 58 and 44%, respectively, in the cohort receiving the highest latiglutenase dose (900 mg, n = 14) relative to placebo (n = 54). Symptom improvement increased from week 6 to week 12. There was also a trend toward greater symptom improvement with greater baseline symptom severity. Conclusions Seropositive CD patients show symptomatic improvement from latiglutenase taken with meals and would benefit from the availability of this treatment.
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Celiac disease (CD) is an immune-mediated inflammatory enteropathy triggered by gluten exposure in genetically susceptible individuals. It has a high prevalence approaching 1% of the US population. A high index of suspicion is warranted to diagnose CD as frequently patients present with extraintestinal or atypical manifestations. CD is diagnosed by a combination of serum serologies and duodenal biopsies. The majority of patients will respond to a lifelong gluten-free diet which is the cornerstone of therapy. Complications such as refractory CD, ulcerative jejunoileitis, enteropathy associated T-cell lymphoma and small bowel adenocarcinoma occur in a minority of patients.
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Objectives Treatment for celiac disease (CD) is a lifelong strict gluten-free diet (GFD). Patients should be followed-up with dietary interviews and serology as CD markers to ensure adherence to the diet. However, none of these methods offer an accurate measure of dietary compliance. Our aim was to evaluate the measurement of gluten immunogenic peptides (GIP) in stools as a marker of GFD adherence in CD patients and compare it with traditional methods of GFD monitoring. Methods We performed a prospective, nonrandomized, multicenter study including 188 CD patients on GFD and 84 healthy controls. Subjects were given a dietary questionnaire and fecal GIP quantified by enzyme-linked immunosorbent assay (ELISA). Serological anti-tissue transglutaminase (anti-tTG) IgA and anti-deamidated gliadin peptide (anti-DGP) IgA antibodies were measured simultaneously. Results Of the 188 celiac patients, 56 (29.8%) had detectable GIP levels in stools. There was significant association between age and GIP in stools that revealed increasing dietary transgressions with advancing age (39.2% in subjects ≥13 years old) and with gender in certain age groups (60% in men ≥13 years old). No association was found between fecal GIP and dietary questionnaire or anti-tTG antibodies. However, association was detected between GIP and anti-DGP antibodies, although 46 of the 53 GIP stool-positive patients were negative for anti-DGP. Conclusions Detection of gluten peptides in stools reveals limitations of traditional methods for monitoring GFD in celiac patients. The GIP ELISA enables direct and quantitative assessment of gluten exposure early after ingestion and could aid in the diagnosis and clinical management of nonresponsive CD and refractory CD. Trial registration number NCT02711397.
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Objective Gluten-free diet (GFD) is the only management for coeliac disease (CD). Available methods to assess GFD compliance are insufficiently sensitive to detect occasional dietary transgressions that may cause gut mucosal damage. We aimed to develop a method to determine gluten intake and monitor GFD compliance in patients with CD and to evaluate its correlation with mucosal damage. Design Urine samples of 76 healthy subjects and 58 patients with CD subjected to different gluten dietary conditions were collected. A lateral flow test (LFT) with the highly sensitive and specific G12 monoclonal antibody for the most dominant gluten immunogenic peptides (GIP) and a LFT reader were used to quantify GIP in solid-phase extracted urines. Results GIP were detectable in concentrated urines from healthy individuals previously subjected to GFD as early as 4–6 h after single gluten intake, and remained detectable for 1–2 days. The urine assay revealed infringement of the GFD in about 50% of the patients. Analysis of duodenal biopsies revealed that most of patients with CD (89%) with no villous atrophy had no detectable GIP in urine, while all patients with quantifiable GIP in urine showed incomplete intestinal mucosa recovery. Conclusion GIP are detected in urine after gluten consumption, enabling a new and non-invasive method to monitor GFD compliance and transgressions. The method was sensitive, specific and simple enough to be convenient for clinical monitoring of patients with CD as well as for basic and clinical research applications including drug development. Trial registration number NCT02344758.
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Purpose: Celiac disease, an immunological response triggered by gluten, affects ~1 % of the Western population. Information concerning gluten intake in the general population is scarce. We determined intake of gluten from wheat, barley, rye and oat in the Danish National Survey of Diet and Physical Activity 2005-2008. The study population comprised a random cross-sectional sample of 1494 adults 20-75 years, selected from the Danish Civil Registration System. Methods: Protein content in wheat, rye, barley and oat was determined from the National Danish Food Composition Table and multiplied with the amount of cereal used in recipes. Amount of gluten was calculated as amount of cereal protein ×0.80 for wheat and oat, ×0.65 for rye and ×0.50 for barley. Dietary intake was recorded daily during seven consecutive days in pre-coded food diaries with open-answer possibilities. Results: Mean total gluten intake was 10.4 ± 4.4 g/day (10th-90th percentiles; 5.4-16.2 g/day), in men 12.0 ± 4.6 g/day and 9.0 ± 3.4 g/day in women. It was higher among men than among women in all age groups (20-75 years; P < 0.0001); however, this difference was eliminated when adjusting for energy intake. Intake of different gluten sources tended to be higher in men than in women with the exception of gluten from barley. Total gluten intake decreased with increasing age (P < 0.0001) as did gluten intake from wheat (P < 0.0001), whereas intake of gluten from rye (P < 0.0001) and barley (P = 0.001) increased with increasing age, also when adjusted for energy intake or body weight. Conclusion: This study presents representative population-based data on gluten intake in Danish adults. Total gluten intake decreased with increasing age.
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Coeliac disease is a global disease, and the only currently available treatment is a gluten-free diet (GFD). Although conceptually simple, the diet changes are substantial and have a profound effect on a patient's life. Untreated coeliac disease is associated with complications, including excess mortality, most of which can be avoided with a strict GFD. However, there are many barriers, including availability, cost and safety of gluten-free foods, and gluten cross-contamination. The GFD can be restrictive in social situations, leading to poor quality of life and, ultimately, nonadherence. As the number of patients with coeliac disease increases worldwide, clinicians need to be aware of the challenges patients face. Heightened awareness by physicians, dietitians and other providers can help maximize successful treatment, improve outcomes, and reduce health-care costs and disease burden. Routine follow-up is necessary to reinforce the need for a GFD, provide social and emotional support, and achieve mucosal healing, leading to reduced risk of complications. Unfortunately, there is wide variation in follow-up practices. The objective of this Review is to increase awareness of the challenges, management and follow-up of patients with coeliac disease to help them achieve GFD adherence and prevent complications whilst preserving their quality of life.
Background & aims: Gluten ingestion leads to symptoms and small intestinal mucosal injury in patients with celiac disease. The only option is the strict lifelong exclusion of dietary gluten, which is difficult to accomplish. Many patients following a gluten-free diet continue to have symptoms and have small intestinal mucosal injury. Non-dietary therapies are needed. We performed a phase 2 study of the ability of latiglutenase, an orally administered mixture of 2 recombinant gluten-targeting proteases, to reduce mucosal morphometric measures in biopsies from patients with celiac disease. Methods: We performed a double-blind, placebo-controlled, dose-ranging study to assess the efficacy and safety of latiglutenase in 494 patients with celiac disease (with moderate or severe symptoms) in North America and Europe, from August 2013 until December 2014. Participants reported following a gluten-free diet for at least 1 year before the study began. Patients with documented moderate or severe symptoms and villous atrophy (villous height:crypt depth ratio of 2.0 or less) were randomly assigned to groups given placebo or 100, 300, 450, 600, or 900 mg latiglutenase daily for 12 or 24 weeks. Subjects completed the Celiac Disease Symptom Diary each day for 28 days and underwent an upper gastrointestinal endoscopy with duodenal biopsy of the distal duodenum at baseline and weeks 12 and 24. The primary endpoint was change in villous height:crypt depth ratio. Secondary endpoints included numbers of intraepithelial lymphocytes (IELs), serology test results (for levels of antibodies against TG2, DGP, and DGP), symptom frequencies, and safety. Results: In modified intent to treat population, there were no differences between latiglutenase and placebo groups in change from baseline in villous height:crypt depth ration, numbers of IELs, or serologic markers of celiac disease. All groups had significant improvements in histologic and symptom scores. Conclusions: In a phase 2 study of patients with symptomatic celiac disease and histologic evidence of significant duodenal mucosal injury, latiglutenase did not improve histologic and symptom scores when compared to placebo. There were no significant differences in change from baseline between groups. no: NCT01917630.
According to Codex only foods not exceeding a level of 20mg gluten/kg may bear a gluten-free label. This also sets the standard for analytical methods for gluten detection. In this paper the currently used methods for gluten analysis are reviewed and new developments are discussed. At the moment, the most commonly used methods are ELISA-based, but also PCR-based methods have been successfully employed. Proteomics-based methods such as reversed-phase (RP-) or gel permeation (GP-) high-performance liquid chromatography (HPLC) have been widely used for characterisation of cereal proteins. Methods combining mass spectrometry and liquid chromatography (LC-MS/MS) are the most promising non-immunological approaches for accurate quantitation of gluten traces. However, due to its requirement of expensive equipment and expertise it is not widely used for routine analysis. New developments include immunosensors, aptamers, microarrays, and multianalyte profiling. Despite the merits and challenges of the different methods, the need for an independent reference method and a generally applicable reference material remain.
& Aims: Celiac disease (CeD) is a prevalent autoimmune condition. Recurrent signs and symptoms are common despite treatment with a gluten free diet (GFD), yet no approved or proven non-dietary treatment is available. In this multicenter randomized, double-blind, placebo-controlled study, we assessed larazotide acetate 0.5, 1, or 2 mg three times daily to relieve ongoing symptoms in 342 adults with CeD who had been on a GFD for ≥12 months and maintained their current GFD during the study. The study included a 4-week placebo run-in, 12-week treatment, and 4-week placebo run-out phase. The primary endpoint was the difference in average on-treatment Celiac Disease Gastrointestinal Symptom Rating Scale score (CeD-GSRS). The primary endpoint was met at the 0.5 mg dose of larazotide acetate with fewer symptoms compared with placebo by Modified Intention to Treat (n=340) (ANCOVA p=0.022, MMRM p=0.005). The 0.5mg dose showed effect on exploratory endpoints including, 26% decrease in Celiac Disease Patient Reported Outcome Symptomatic Days (p=0.017); 31% increase in Improved Symptom Days (p=0.034); ≥50% reduction from baseline of weekly average Abdominal Pain Score for ≥6 out of 12 weeks of treatment (p=0.022); and a decrease in Non-GI symptoms of headache and tiredness (p=0.010). The 1 and 2 mg doses were no different than placebo for any endpoint. Safety was comparable to placebo. Larazotide acetate 0.5 mg reduced signs and symptoms in CeD patients on a GFD better than a GFD alone. While results were mixed,this study represents the first successful trial of a novel therapeutic agent targeting Tight Junction regulation in patients with CeD who are symptomatic despite a GFD., NCT01396213. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
Celiac disease is a T cell-mediated disease induced by dietary gluten, a component of which is gliadin. 95% of individuals with celiac disease carry the HLA (human leukocyte antigen)-DQ2 locus. Here we determined the T-cell receptor (TCR) usage and fine specificity of patient-derived T-cell clones specific for two epitopes from wheat gliadin, DQ2.5-glia-α1a and DQ2.5-glia-α2. We determined the ternary structures of four distinct biased TCRs specific for those epitopes. All three TCRs specific for DQ2.5-glia-α2 docked centrally above HLA-DQ2, which together with mutagenesis and affinity measurements provided a basis for the biased TCR usage. A non-germline encoded arginine residue within the CDR3β loop acted as the lynchpin within this common docking footprint. Although the TCRs specific for DQ2.5-glia-α1a and DQ2.5-glia-α2 docked similarly, their interactions with the respective gliadin determinants differed markedly, thereby providing a basis for epitope specificity.