Gluten sensitivity and new therapies: what does the future hold?

Gluten sensitivity, medically known as coeliac disease, is affecting more and more people around the world. For people living with this chronic, autoimmune disease, eating foods containing gluten can cause unpleasant and often painful symptoms and, in the long term, serious complications. The only effective therapy at present is a strict, lifelong gluten-free diet. But are new treatment options on the horizon? In this article, we take a detailed look at the background to celiac disease, diagnostic methods, the pitfalls of diet and promising new therapeutic directions that may offer hope to patients.

Living with gluten intolerance can be challenging. Ongoing dietary restrictions, avoidance of hidden sources of gluten and difficulties attending social events can all be stressful. It is therefore important that patients are not only aware of their current treatment options, but also of the research that is going on. Visit Endomedix Gastroenterology Centre experts are committed to providing the most up-to-date knowledge and care to those who turn to them. This article provides a comprehensive overview of where medicine stands today in the treatment of celiac disease and practical advice to make everyday life easier.

What exactly is gluten sensitivity (coeliac condition)?

Coeliac disease (also known as celiac disease or gluten-sensitive enteropathy) is an autoimmune disease triggered by gluten - a protein in wheat, rye and barley - in genetically susceptible individuals. It is important to distinguish it from non-celiac gluten sensitivity (NCGS) and wheat allergy, as they have different backgrounds and treatments.

In coeliac disease, the body's immune system attacks the lining of the small intestine as an abnormal response to gluten. This process leads to atrophy of the intestinal tubules, which are essential for the proper absorption of nutrients. When the intestinal lining is damaged, the body is unable to absorb vitamins, minerals and other essential nutrients efficiently, which can lead to severe deficiencies and other health problems. The disease can develop at any age, from infancy to old age.

Symptoms and diagnosis of gluten sensitivity

The symptoms of coeliac condition can be extremely varied, which often makes diagnosis difficult. The severity and nature of symptoms vary from person to person.

Typical symptoms

Classical coeliac disease (typically in childhood):

• Gastrointestinal symptoms: Chronic or recurrent diarrhoea, large, greasy, foul-smelling stools, abdominal distention, loss of appetite, vomiting.
• Physical signals: Pale skin, stunted growth, muscle atrophy, reduced skin tone, thinning, split hair.
• Psychological changes: Mood swings, irritability, lethargy.

Non-classical celiac disease (common in adulthood):

• Gastrointestinal symptoms: Milder, less typical complaints such as recurrent abdominal pain, bloating, alternating bowel movements (alternating between diarrhoea and constipation).
• General symptoms: Chronic fatigue, iron deficiency anaemia, osteoporosis, weight loss, joint pain.

Extraintestinal (outside the gut) manifestations:

• Dermatitis Herpetiformis (Duhring's disease): This is a characteristic skin symptom of celiac disease. It appears as a highly itchy, blistered rash, most often on the elbows, knees, buttocks and back of the neck.
• Neurological problems: Headaches, migraines, balance disorders (gluten ataxia).
• Reproductive disorders: Menstrual problems, infertility, miscarriages.

Steps to diagnosis

The diagnosis of coeliac disease is a multi-step process. If the symptoms lead to suspicion, the following tests are required:

• Serological tests: Blood samples can detect autoantibodies specific for celiac disease. These include antibodies against tissue transglutaminase (tTG), endomysium (EMA) and deamidated gliadin peptide (DGP). It is important that the patient does not switch to a gluten-free diet before the test is performed as this may give a false negative result.
• Genetic testing: Testing the HLA-DQ2 and HLA-DQ8 genes can help to rule out celiac disease. If these genes are missing, the chances of developing celiac disease are extremely low. However, a positive result alone is not sufficient for diagnosis, as a significant proportion of the population carry these genes without being ill.
• Endoscopy and biopsy: To confirm the diagnosis, a gastroscopy (gastroscopy) is essential, during which a tissue sample (biopsy) is taken from the upper part of the small intestine (duodenum). Histopathological examination reveals the extent of damage to the intestinal lining (Marsh classification).

From Endomedix Gastroenterology Centre has modern diagnostic equipment and experienced specialists to help patients make an accurate diagnosis.

Current therapy: the challenges of a gluten-free diet

Currently, the only accepted treatment for celiac disease is a strict, lifelong gluten-free diet. This means avoiding all food and drink containing wheat, rye, barley or their derivatives.

Prohibited foods:

• Wheat (also spelt, durum wheat), rye, barley.
• Traditional pastries, pastries, cakes.
• Semolina, couscous, bulgur.
• Breaded dishes, malt.
• Beer, whisky and other grain spirits.
• Many processed foods can contain hidden gluten (e.g. soup powders, cold cuts, sauces, seasonings).

Authorised foods:

• Maize, rice, potatoes, buckwheat, millet, quinoa, amaranth.
• Vegetables, fruits.
• Meat, fish, eggs (in natural form).
• Milk and natural dairy products.
• Legumes, oil seeds.
• Products specifically marked as gluten-free.

Although the diet is effective in relieving symptoms and preventing complications, it is a heavy burden for patients to follow. Accidental dietary errors due to hidden gluten are common, and even small amounts of gluten can reactivate the immune response and symptoms. In addition, gluten-free products are more expensive and harder to obtain, and social meals require constant attention. This is why researchers worldwide are intensively looking for therapeutic options to complement or replace diet.

New therapeutic directions in the treatment of coeliac disease

Research is being conducted on several fronts, with the aim of reducing the burden of a gluten-free diet and improving patients' quality of life. New therapeutic strategies fall into three main categories:

1. „Disposing” of gluten”

These therapies aim to break down or modify gluten before it can trigger an immune response in the small intestine.

• Enzyme therapies: They develop oral enzymes that can break down immunogenic parts of gluten (peptides) into smaller, harmless pieces in the stomach and small intestine. One such agent currently in the clinical trial phase is latiglutenase. Although these enzymes are unlikely to allow unlimited gluten consumption, they can help prevent the adverse effects of accidental gluten exposure (cross-contamination).
• Polymer therapy: Another approach is to develop a polymer that binds gluten molecules in the stomach, preventing them from being broken down and absorbed in the small intestine. The bound gluten then simply passes through the digestive system and is passed in the faeces.

2. Influencing the permeability of the intestinal wall

A key factor in the development of coeliac disease is the passage of gluten peptides between the cells of the intestinal wall and into the cells of the immune system.

• Zonulin inhibitors: Zonulin is a protein that regulates the tight junctions between cells in the intestinal wall. In coeliac disease, gluten increases the production of zonulin, which makes the intestinal wall „permeable”. A larazotide acetate is a zonulin antagonist that prevents an increase in the permeability of the intestinal wall. The results of clinical trials show that the agent can reduce symptoms following gluten exposure and can therefore be used as an adjunct therapy to diet.

3. Modulating the immune response

These are the most complex but also the most promising strategies to „reprogram” the immune system to tolerate gluten.

• Vaccine therapy (immunotherapy): with Nexvax2 was a therapeutic vaccine developed specifically for celiac disease patients carrying the HLA-DQ2 gene variant. The vaccine was designed to desensitise the immune system by administering specific gluten peptides, similar to allergy immunotherapies. Unfortunately, clinical trials have been stopped because the vaccine has not been shown to be effective, but research is continuing along this route.
• T-cell therapy: Researchers are investigating drugs that inhibit the presentation of gluten to immune cells (T cells) or block the production of inflammatory substances (cytokines such as interleukin-15) that maintain inflammation in the gut.

This research is still at an early stage and it could take years before a new drug is on the market. But they are a clear sign that medical science is making great strides towards providing effective solutions for people with celiac disease beyond a gluten-free diet.

What next? Visit our specialists!

Gluten intolerance is a complex disease that requires constant medical supervision and personalised care. Although new therapies are promising, accurate diagnosis and adherence to the most effective treatment currently available - a gluten-free diet - are the most important today. Monitoring the effectiveness of the diet, preventing and treating deficiencies and screening for complications are essential for long-term well-being.

If you have symptoms suggestive of coeliac condition, or if you are a diagnosed patient and have questions about your condition, please contact the Endomedix Gastroenterology Centre professionals. Our experienced gastroenterologists and dietitians can help you to make an accurate diagnosis, develop a personalised diet and successfully manage your disease in the long term. Don't be alone with your questions, make an appointment today!