One symptom and one biomarker identify gluten exposure

Coeliac disease

By Michael Woodhead

28 Nov 2019

People with coeliac disease on a gluten free diet often attribute IBS-like symptoms to inadvertent gluten ingestion, but Australian research has shown that nausea is the key symptom of acute gluten exposure.

And in another novel finding, gluten-induced nausea was also significantly correlated with elevated levels of the cytokine serum interleukin‐2, suggesting this could be used as a biomarker of gluten-related immune activation.

In a study involving 36 patients with coeliac disease, researchers led by Queensland University gastroenterologist Dr James Daveson tested the effects of masked gluten and sham food exposure challenges, taking care to use a low FODMAPS foods to avoid overlap with IBS-like symptoms.

Based on Coeliac Disease Patient Reported Outcome (CeD PRO) symptom scores, nausea was the most prominent symptom seen after gluten exposure. There were few other symptoms other than some tiredness and headache. The sham food challenge was not associated with significant symptom induction.

Nausea was the only one of nine symptoms that differed significantly in severity and occurrence after gluten challenge compared to sham challenge.

Interleukin‐2 was elevated after gluten in 97% of patients and correlated with severity of nausea and occurrence of vomiting (P = .0005). There was no elevation of interleukin-2 after sham food ingestion.

“Overall, elevation in serum interleukin‐2 was 97% sensitive and 100% specific for patients exposed to gluten compared to sham, whereas the symptom complex with nausea as its sentinel symptom was 69% sensitive and 89% specific for patients exposed to gluten compared to sham,” said the study authors.

They said IBS‐like symptoms were commonly reported in coeliac disease, but the new findings suggested they may be a nonspecific effect of mucosal inflammation rather than directly linked to gluten‐mediated immune activation.

“This is an important clinical consideration, as both patients with coeliac disease and their treating clinicians frequently attribute persistent symptomatology to accidental gluten exposure.

“Our findings suggest that it is important to consider nongluten driven causes for symptomatology such as FODMAPs driving IBS,” they wrote in Alimentary Pharmacology and Therapeutics.

The results also suggested that interleukin-2 could be used as a biomarker for endpoints assessment in coeliac disease trials. And knowledge of nausea as the sentinel exposure symptom could be used in dietary education for patients with newly diagnosed coeliac disease.

“Understanding what symptoms are indicative of recent gluten exposure could allow patients to recognise and avoid foods or situations that increase the likelihood of gluten contamination, and clinicians to advise accordingly,” they said.

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