Clinical Question

Does testing for celiac disease and subsequent treatment with a gluten-free diet benefit asymptomatic patients with markers of celiac disease?

Bottom Line

Screening of asymptomatic relatives of patients with known celiac disease identified approximately 5% who were antibody-positive. Compared with their normal diet, a gluten-free diet improved some yet unrecognized symptoms but seemed to interfere with normal social activities in these patients. These results will not apply to patients at low risk of celiac disease or those with gluten sensitivity who choose a gluten-free diet. (Level of Evidence = 1b)

Synopsis

The Finnish researchers conducting this study started by recruiting adult relatives of patients with known celiac disease. After screening 3,031 relatives the researchers identified 148 (4.9%) who tested positive for endomysial antibodies. Patients underwent small intestine biopsy at baseline, after one year, and after two years, but the results were not analyzed until after the study was concluded. After excluding patients with symptoms, the authors randomized the 40 remaining patients to continue their normal diet or to begin a gluten-free diet. Of those assigned to the gluten-free diet, 92% said they adhered to it for one year. After one year, participants were given the choice to change diets.

At the end of the study, small intestine morphology (mucosal villous height) and celiac-associated antibodies improved without gluten. Here's where it gets interesting: Using the Gastrointestinal Symptoms Rating Scale to detect previously unrecognized symptoms, indigestion and reflux symptoms were significantly improved. Anxiety scores were improved to a greater extent on the Psychological General Well-Being Index. Other items on both surveys were not changed, although the study may have been too small to find a difference. However, social function, which is the degree of interference with normal social activities because of physical and emotional problems, was significantly better with a normal (gluten-containing) diet (P = .031). At the end of two years, 85% of the gluten-free diet group planned to remain gluten free. This study points out two important clinical points: Widespread screening for celiac disease even among high-risk persons is of low yield, and treatment with a gluten-free diet produces mixed benefits.

Study design: Randomized controlled trial (nonblinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: KurppaKPaavolaACollinPet alBenefits of a gluten-free diet for asymptomatic patients with serologic markers of celiac disease. Gastroenterology.2014; 147( 3): 610.e1– 617.e1.