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      Drugs & Diseases > Gastroenterology

      Celiac Disease (Sprue) Treatment & Management

      Updated: Nov 29, 2019
      • Author: Stephan U Goebel, MD; Chief Editor: BS Anand, MD  more...
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      Treatment

      Medical Care

      Diet

      The primary management of celiac disease is dietary, but research into novel nondietary therapy is ongoing. [6, 7] Complete elimination of gluten-containing grain products (including wheat, rye, and barley) is essential to treatment. [31, 20, 32]  Although the majority of patients will celiac disease respond to a gluten-free diet, persistent/recurrent symptoms affect up to 20%. [8] Moreover, complete avoidance of gluten-containing grain products is relatively difficult for patients to achieve and maintain because certain products, such as wheat flour, are virtually ubiquitous in the American diet.

      To facilitate elimination of gluten from the diet, the US Food and Drug Administration (FDA) has released rules providing uniform food-label definitions of “gluten-free.” [33, 34] By these rules, foods so labeled—as well as those that claim to contain “no gluten” or to be “free of gluten” or “without gluten"—must contain fewer than 20 parts of gluten per million. The European Union and Canada have implemented the same standards. [33]

      After an initial period of avoidance, oats might be reintroduced into the diet of patients with celiac disease. These patients should be monitored carefully for recurrent symptoms. Careful and extensive indoctrination of the patient by the physician and the dietitian is often necessary to achieve full compliance.

      Timing of gluten introduction

      Two studies have suggested that the timing of gluten exposure does not affect the likelihood of developing celiac disease in children at high risk for the condition. [35, 36, 37]  The first study, which examined whether early exposure to gluten was protective against celiac disease, involved 944 children who were positive for the human leukocyte antigen (HLA) haplotype DQ2 or DQ8 and had at least one first-degree relative with celiac disease. Starting at age 16 weeks and continuing daily for 8 weeks, the infants received either 200 mg of vital wheat gluten mixed with 1.8 g lactose (the equivalent of 100 mg of immunologically active gluten) or placebo. [35, 36]

      The children were followed up at age 3 years, at which time the cumulative incidence of celiac disease was 5.9% in the gluten group and 4.5% in the placebo group. It was also found that among girls, the cumulative incidence of celiac disease was higher in the gluten group than in the placebo group (8.9% vs 5.5%, respectively), although no such difference was found between boys in the two groups. Another finding was that the duration of breastfeeding (ie, whether the breastfeeding was exclusive or whether it was continued during gluten introduction) had no significant effect on the development of celiac disease. [35, 36]

      The second study looked at whether delayed timing of gluten introduction was protective. More than 550 children who were positive for HLA-DQ2 and/or HLA-DQ8 and had at least one first-degree relative with celiac disease were randomized to be introduced to gluten-containing food at either age 6 months or age 12 months. By age 2 years, the incidence of overt celiac disease was 12% in the early gluten group and 5% in the late group, but by age 5 years, the incidence in both groups was 16%. Celiac disease autoimmunity was also more prevalent by age 2 years in the early gluten group than in the late group (16% vs 7%, respectively), but again evened out (21% vs 20%, respectively) by age 5 years. [35, 37]

      Thus, the later introduction of gluten in this study did not seem to affect the risk of celiac disease but may have delayed its onset, with the median age of diagnosis being 26 months in the early group and 34 months in the late group. Similar to the first study, the duration of breastfeeding did not appear to affect the risk of celiac disease in either group. [35, 37]

      Corticosteroids

      A small percentage of patients with celiac disease fail to respond to a gluten-free diet. In some patients who are refractory, corticosteroids might be helpful. In patients who fail to respond to corticosteroids, other comorbid conditions, such as lymphomas of the small intestine, have to be ruled out.

      Consultations

      Consider consultations with a dietitian and nutritionist.

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