Non-dietary forms of treatment for adult celiac disease

Abstract

At present, treatment for celiac disease includes a strict gluten-free diet. Compliance, however, is difficult and gluten-free food products are costly, and, sometimes very inconvenient. A number of potential alternative measures have been proposed to either replace or supplement gluten-free diet therapy. In the past, non-dietary forms of treatment were used (e.g., corticosteroids) by some clinicians, often to supplement a gluten-free diet in patients that appeared to be poorly responsive to a gluten-free diet. Some of new and novel non-dietary measures have already advanced to a clinical trial phase. There are still some difficulties even if initial studies suggest a particularly exciting and novel form of non-dietary treatment. In particular, precise monitoring of the response to these agents will become critical. Symptom or laboratory improvement may be important, but it will be critical to ensure that ongoing inflammatory change and mucosal injury are not present. Therapeutic trials will be made more difficult because there is already an effective treatment regimen.

Keywords: Adult celiac disease; Gluten-free diet; Non-dietary treatment of celiac disease; Tight junction inhibition; Protease; Immunotherapy; Vaccination

Core tip: Non-dietary forms of treatment for adult celiac disease are currently being evaluated and some have reached clinical trials. Some novel approaches being investigated include hydrolysis of gliadin peptides, inhibition of intestinal permeability, blockade of T lymphocytes and transglutaminase 2/human leukocyte antigen-DQ2 functions as well as induction of immune tolerance. Future evaluations will need to define effects on specific endpoints and ensure an improvement in symptoms, laboratory test results and, most important, mucosal inflammatory changes. Therapeutic trials with novel agents will be difficult from an ethical perspective as the current form of management with a gluten-free diet already provides an excellent result for most compliant patients with celiac disease. Finally, effects on other known superimposed diseases will need close evaluation (i.e., lymphoproliferative and other malignancies).