Celiac Disease: Looking Forward

At the 2018 Canadian Digestive Diseases Week (CDDW) in Toronto, gastroenterologists spoke about some of the challenges – and the exciting new possibilities – of treating celiac disease. In this article, we’ll focus on the current state of celiac disease treatment, and potential medications that we might see in the future.

What is Celiac Disease?

Celiac disease is an autoimmune gastrointestinal condition in which a substance called gliadin (a grain protein in gluten) causes damage to the inner lining of the small intestine. In those with celiac disease, gliadin triggers an unusual immune response that leads to flattening and altering of the millions of microscopic finger-like projections (villi) that line the inner wall of the small intestine. This makes it difficult for the body to absorb enough essential proteins, fats, carbohydrates, vitamins, and minerals from food. To date, the only treatment method available for celiac disease is a total gluten-free diet.

How Effective is the Gluten-Free Diet?

Treating celiac disease sounds incredibly simple: avoid gluten and your symptoms will disappear, your intestinal tract will heal, and you can live a normal, healthy life. Yet, for some, adequately treating celiac disease can feel impossible. While the gluten-free diet is great in theory, and it does work perfectly for many who have celiac disease, an alarming number of those who do their best to follow a gluten-free diet still manage to consume gluten and continue experiencing symptoms. Almost a third of those with celiac disease who follow a gluten-free diet are non-responsive to this treatment, likely due to consuming small amounts of gluten, often accidentally.¹ This can happen for a number of reasons, including cross-contamination at restaurants, not reading labels, and not being aware of some surprising sources of gluten (such as processed meats, candies, medications, and supplements). In addition, a further 1-2% have refractory celiac disease,² which occurs when the intestine does not heal, even while maintaining a careful gluten-free diet.

Even in those who are thoroughly educated as to which foods and products contain gluten, many still slip-up. For some individuals, managing new diet plans and avoiding food in social situations can seem like an impossible hurdle, and many who are diagnosed with celiac disease later in life find it tough to change lifelong eating habits. This can mean that those with celiac disease knowingly eat gluten from time-to-time.

Despite how easy the gluten-free diet seems on paper, those with celiac disease may have a perceived burden of treatment that is higher than it is for those with diseases that many would consider more difficult to treat, such as inflammatory bowel disease and diabetes.³ A major dietary overhaul can affect most aspects of life, and many individuals find it much harder to manage than adhering to a medication regimen.

Is the Gluten-Free Diet Really the Best We Can Do?

We mentioned one medication in our article, The Future of Celiac Disease, in issue 195 of the Inside Tract®, but there are many others in development. For some time, researchers have had little interest in formulating medications for celiac disease because, unlike many other diseases and disorders, there is already an effective celiac treatment that anyone can do at home. However, with more evidence pointing to the fact that it doesn’t quite work for everyone, researchers are getting on board with the idea of medications for treating celiac disease. The one benefit that celiac disease has compared to many other diseases and disorders is that when it comes to formulating treatments, we know the cause.

Current Research

There are many new and exciting possibilities that could allow those with celiac disease to eat gluten one day without experiencing intestinal damage and negative side effects.

Researchers are focusing on many mechanisms, but most of these medications aim to do something similar: prevent gliadin from damaging the intestinal tract. A straightforward approach that some are looking at involves using enzymes to degrade the gliadin and render it inert, or using binders, products that attach to the gliadin and cause it to pass through the digestive system without harming the intestine. One medication type, tight junction regulators, aims to help heal intestinal permeability in the lumen, preventing gluten from passing through. Researchers are putting effort into several other medication types, including medications that block a protein called interleukin-15, tolerogenic immune-modifying nanoparticles, and transglutaminase 2 inhibitors. There is even the possibility of a vaccine to help celiac patients build up resistance to gliadin.

It is unlikely that first generation medications will allow those with celiac disease to eat a standard diet, but they might be ideal for those who follow a gluten-free diet to the best of their abilities, but still ingest small amounts of gluten.

Transitioning from Child to Adult Care

Celiac disease is often diagnosed early in life, at a time when most children rely entirely on their parents or guardians to help them manage their disease. For these kids, reaching adulthood can be jarring. Along with managing the new aspects of adulthood that others their age deal with, these young people must learn how to take over their disease care from their parents. Managing a gluten-free diet is often tough for them, and many young adults consume gluten sometimes, which can have devastating effects on their health at this critical time of life.

At CDDW, they discussed ways to ensure this transition from childhood to adulthood goes as smoothly as possible. First, it is important for parents to involve their children in their disease care considerably earlier than when they go off to college, ideally by 13 years-of-age. At this time, parents should focus on explaining to their child how celiac disease works, what it means for them, and how to manage a gluten-free diet. It’s also important for pediatric gastroenterologists to help the children they care for continue to get help once they age out of child specialists by referring them to gastroenterologists who treat adults. In one study reported during the CDDW conference, only 33% of young adults with celiac disease followed up with their gastroenterology care when they did not receive a referral to an adult gastroenterologist, compared to 76% of those whose primary care physician or pediatric gastroenterologist gave a referral to an adult gastroenterologist.

First published in the Inside Tract® newsletter issue 205 – 2018

1. Dewar DH et al. Celiac disease: Management of persistent symptoms in patients on a gluten-free diet. World Journal of Gastroenterology. 2012;18(12):1348–1356.
2. Malamut G et al. Refractory celiac disease: epidemiology and clinical manifestations. Digestive Diseases. 2015;33(2):221-6.
3. Shah S et al. Patient Perception of Treatment Burden is High in Celiac Disease Compared to Other Common Conditions. American Journal of Gastroenterology. 2014;109(9):1304–1311.