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    Strong Link Between Asthma and Celiac Disease


    Jefferson Adams

    Celiac.com 04/07/2011 - People with celiac disease are 60 percent more likely to develop asthma than people without celiac disease, according to a new study, which appears in the Journal of Allergy and Clinical Immunology.


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    Moreover, the study results show that those with asthma are also more likely to eventually develop celiac disease. Indeed, for every 100,000 people with celiac disease, 147 will have asthma that would not have occurred in the absence of the digestive disorder.

    To assess possible links between celiac disease and asthma, Dr. Jonas Ludvigsson of Orebro University Hospital and the Karolinska Institutet in Sweden and colleagues compared more than 28,000 Swedes diagnosed with celiac to more than 140,000 similar people without the disease.

    Ludvigsson cautions that the study merely shows an links between the two diseases, it does not establish that asthma causes celiac disease, or vice versa.

    The exact nature of the association between the two diseases is unclear, but Ludvigsson told reporters that he thinks "the role of vitamin D deficiency should be stressed."

    Ludwigsson points out that people with celiac are more likely to develop osteoporosis and tuberculosis, both diseases in which vitamin D plays a role. If a person with celiac also has low levels of vitamin D, this could in turn affect the immune system, which could increase the risk of developing asthma.

    Another possibility, he points out, is that "asthma and celiac disease share some immunological feature. If you have it, you are at increased risk of both diseases.

    Ludvigsson also addresses the fact that the study did not establish levels of compliance with a gluten-free diet among the participants with celiac disease by noting that general "dietary compliance is high in Sweden," so he believes that "patients with good adherence are at increased risk of asthma."

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    Guest ACurtis

    Posted

    I have gluten intolerance and also a casein allergy (along with soy intolerance and intolerances to about 21 other foods).

     

    Once I quit eating cow dairy (I can eat goat or sheep products) and cut out all the other foods that were having inflammatory responses within my body, I was able to go off Advair. I'd been on Advair since about 2003 and went off it in April 2010. Haven't had any wheezing--even during the winter--and haven't had to use any emergency inhalers, nor anything having to do with asthma control. My asthma...just went away.

     

    So yes, I firmly believe that if you control the aspects of ill health that need controlling--quit eating gluten, quit eating cow milk, quit eating soy, quit eating whatever it is that is making your body inflamed and causing issues--that you could very well get rid of your asthma and off the asthma pharma drugs. Probably other allergies as well, as many of mine have also gone away.

     

    I also went off all the pharma drugs I'd been on, started eating organic food and quit eating processed stuff, and take specific supplements/nutriceuticals that my body is lacking, as well as drinking reverse-osmosis water. I think doing a multitude of good, clean living items--to include detoxifying and cleaning up the body--definitely helps the body repair itself and get healthy.

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    Guest Tim Harper

    Posted

    I have gluten intolerance and also a casein allergy (along with soy intolerance and intolerances to about 21 other foods).

     

    Once I quit eating cow dairy (I can eat goat or sheep products) and cut out all the other foods that were having inflammatory responses within my body, I was able to go off Advair. I'd been on Advair since about 2003 and went off it in April 2010. Haven't had any wheezing--even during the winter--and haven't had to use any emergency inhalers, nor anything having to do with asthma control. My asthma...just went away.

     

    So yes, I firmly believe that if you control the aspects of ill health that need controlling--quit eating gluten, quit eating cow milk, quit eating soy, quit eating whatever it is that is making your body inflamed and causing issues--that you could very well get rid of your asthma and off the asthma pharma drugs. Probably other allergies as well, as many of mine have also gone away.

     

    I also went off all the pharma drugs I'd been on, started eating organic food and quit eating processed stuff, and take specific supplements/nutriceuticals that my body is lacking, as well as drinking reverse-osmosis water. I think doing a multitude of good, clean living items--to include detoxifying and cleaning up the body--definitely helps the body repair itself and get healthy.

    Certainly glad to hear this, ACurtis.

     

    I've recently been diagnosed with celiac disease. Before that, I had two bouts with asthma that were warded off by a low-glycemic cleansing diet prescribed by my doctor. I discovered that cow milk brought my asthma back instantly. In retrospect, it's clear that I only addressed part of the problem. 6 months ago, I had asthma onset strong and hard, and have desperately been trying to understand the sudden decline in my health. I've started a gluten-free diet, and have been free from the aforementioned refined sugars and foods for a long, long time now. My diet consists of more than 50% fruits and vegetables, some organic, some not, always raw. Asthma was getting worse steadily to the point of near-hospitalization, to the point where no combination of Prednasone, Advair, Dulera, nor Singular could make me feel better. Recently, my asthma has made a turn for the better. I fear the winter the most, as that's when my previous asthma symptoms onset. Hopefully I can experience a similar recovery as you have.

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    Guest brian ahern

    Posted

    10 days on a gluten-free diet have made my asthma inhaler obsolete. I think they have found the tip of an iceberg here. An AgA blood test came in at a high "normal" and thus negative for celiac, but the gluten-free diet has helped me immensely. I am also noticing a huge improvement in my sinuses. My childhood included unexplained outbreaks of eczema, and what I thought was a spastic colon. These seemed benign compared to suffocating asthma. I am no doctor but my hunch is that there is an issue of magnesium malabsorption in celiac disease, which may prevent smooth lung tissue from relaxing in asthmatics (probably a stretch, but who knows). Perhaps in twenty years dietitians and gastroenterologists will be the real asthma experts.

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  • Related Articles

    Diana Gitig Ph.D.
    Celiac.com 03/21/2011 - Two recent population-based studies, both performed in Sweden by Dr. Jonas Ludvigsson, have concluded that people who have had biopsies that reveal villous atrophy are at increased risk of both ischemic heart disease and asthma. But at least regarding heart disease, the bulk of the risk may simply be attributable to inflammation.
    The team of researchers looked at biopsy data collected from all twenty-eight of Sweden’s pathology departments between 2006 and 2008. The data included biopsies performed as far back as 1969, and represented 44,446 individuals: 28,190 with celiac disease, as ascertained by small intestine morphology; 12,598 with duodenal/jejuna inflammation lacking villous atrophy; and 3,658 with latent celiac disease, defined as those with positive celiac serology but normal mucosa. 219,392 healthy controls who had never had biopsies were included as controls. They concluded that celiac disease and inflammation of the small intestine were both modestly associated with ischemic heart disease, whereas latent celiac disease was not.
    Although these findings agree in kind, if not in degree, with reports previously published by others, this study had a number of flaws. First of all, the researchers lack data on individual adherence to a gluten free diet. The authors note that “low dietary adherence is associated with persistent inflammation and therefore might explain the increased risk of ischemic heart disease observed in patients with celiac disease.” They also lack data on blood pressure, smoking status, body mass index, lipid levels, exercise routines, and other established risk factors for ischemic heart disease. Because they found the highest risk in the first year following biopsy, they cede that this risk could be attributable to enhanced inflammation, enhanced stress surrounding a diagnosis with celiac disease, or even an increase in reporting rather than incidence due to more vigilant medical care immediately following the diagnosis with celiac disease. They even note that gastrointestinal and cardiac symptoms are easily confused, further confounding their analysis.
    The second study compared the same 28,190 Swedes with villous atrophy to 140,000 controls. It reported that people with celiac disease were 60% more likely to develop asthma than those without it, and conversely, that people with asthma are more likely to develop celiac disease. “A potential mechanism could be that asthma and celiac disease share some immunological feature,” said Dr. Ludvigsson. “If you have it, you are at increased risk of both diseases.” He also noted that vitamin D deficiency can play a causative role in both diseases, and should be assessed on both celiac patients and asthmatics.
    Sources:
    Circulation 2011; 123: 483-490 Journal of Allergy and Clinical Immunology February 11, 2011 / doi:10.1016/j.jaci.2010.12.1076

    Tina Turbin
    Celiac.com 05/20/2011 - Over the years, researchers have been discovering more and more about celiac disease, an autoimmune disease which is caused by gluten, a protein found in wheat, barley, and rye. Studies have linked the disease to a variety of other medical conditions, such as irritable bowel syndrome, rheumatoid arthritis, and osteoporosis. Researchers have now found a connection between celiac disease and asthma.

    Asthma is chronic lung disease that causes the passages of the lungs to become inflamed and narrowed, resulting in wheezing, shortness of breath, tightness in the chest area, and coughing. It often begins in childhood, and according to the U.S. Department of Health and Human services, more than 22 million people suffer from the condition. Many studies have linked asthma to airborne allergens, but doctors have begun to look into food culprits as well. One such study shows a connection to celiac disease, which isn’t an allergy but rather an autoimmune response to gluten.

    In a study published in the Journal of Allergy and Clinical Immunology, European researchers found that celiac individuals were 60 percent more likely to develop asthma than those without the condition. Celiac disease affects approximately one percent of the population and without treatment, which is a gluten-free diet, can cause a variety of physical and mental symptoms including chronic fatigue, headaches, malnutrition, chronic headaches, and stomach problems.

    Dr. Jonas Ludvigsson of Orebro University Hospital and the Karolinska Institutet in Sweden and his colleagues compared more than 28,000 Swedish celiac patients to more than 140,000 similar people without the disease. The study concluded that only a link between the two could be demonstrated, not that one condition causes the other; the researchers weren’t able to identify the reason for the association.

    One possible factor may be Vitamin D. According to Reuters Health, Dr. Ludvigsson said in an email, "Personally, I think the role of vitamin D deficiency should be stressed." Vitamin D has been demonstrated to be a factor in the development of tuberculosis and osteoporosis, both of which celiacs are more likely to develop. In celiac disease, gluten causes an autoimmune reaction that causes the immune system to attack the small intestine, specifically the villi, the finger-like structures that absorb the nutrients from food; thus celiac patients usually exhibit deficiencies in vitamins and minerals. If a celiac patient isn’t getting enough vitamin D into their system, according to Dr. Ludvigsson, the risk for asthma disease may be increased.

    According to Dr. Ludviggson, Swedish celiac patients adhere well to the gluten-free diet. The study didn’t determine how closely the 28,000 subjects were sticking to their diets, but Ludviggson told Reuters health, "Generally dietary compliance is high in Sweden, so I actually believe that also patients with good adherence are at increased risk of asthma.”

    It is recommended that people who suspect they may have celiac disease or asthma should consult with a qualified medical practitioner for testing, diagnosis, and treatment.
    Resources:

    U.S. Department of Health & Human Services: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html Gluten Free Society: Gluten Sensitivity Increases the Risk for Asthma: http://www.glutenfreesociety.org/gluten-free-society-blog/gluten-sensitivity-increases-the-risk-for-asthma/ Reuters: Asthma linked to celiac disease: http://www.reuters.com/article/2011/02/24/us-asthma-linked-celiac-disease-idUSTRE71N4WF20110224

  • Recent Articles

    Jefferson Adams
    Celiac.com 06/18/2018 - Celiac disease has been mainly associated with Caucasian populations in Northern Europe, and their descendants in other countries, but new scientific evidence is beginning to challenge that view. Still, the exact global prevalence of celiac disease remains unknown.  To get better data on that issue, a team of researchers recently conducted a comprehensive review and meta-analysis to get a reasonably accurate estimate the global prevalence of celiac disease. 
    The research team included P Singh, A Arora, TA Strand, DA Leffler, C Catassi, PH Green, CP Kelly, V Ahuja, and GK Makharia. They are variously affiliated with the Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Lady Hardinge Medical College, New Delhi, India; Innlandet Hospital Trust, Lillehammer, Norway; Centre for International Health, University of Bergen, Bergen, Norway; Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Gastroenterology Research and Development, Takeda Pharmaceuticals Inc, Cambridge, MA; Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy; Department of Medicine, Columbia University Medical Center, New York, New York; USA Celiac Disease Center, Columbia University Medical Center, New York, New York; and the Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
    For their review, the team searched Medline, PubMed, and EMBASE for the keywords ‘celiac disease,’ ‘celiac,’ ‘tissue transglutaminase antibody,’ ‘anti-endomysium antibody,’ ‘endomysial antibody,’ and ‘prevalence’ for studies published from January 1991 through March 2016. 
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    Rates of celiac disease were 0.4% in South America, 0.5% in Africa and North America, 0.6% in Asia, and 0.8% in Europe and Oceania; the prevalence was 0.6% in female vs 0.4% males. Celiac disease was significantly more common in children than adults.
    This systematic review and meta-analysis showed celiac disease to be reported worldwide. Blood test data shows celiac disease rate of 1.4%, while biopsy data shows 0.7%. The prevalence of celiac disease varies with sex, age, and location. 
    This review demonstrates a need for more comprehensive population-based studies of celiac disease in numerous countries.  The 1.4% rate indicates that there are 91.2 million people worldwide with celiac disease, and 3.9 million are in the U.S.A.
    Source:
    Clin Gastroenterol Hepatol. 2018 Jun;16(6):823-836.e2. doi: 10.1016/j.cgh.2017.06.037.

    Jefferson Adams
    Celiac.com 06/16/2018 - Summer is the time for chips and salsa. This fresh salsa recipe relies on cabbage, yes, cabbage, as a secret ingredient. The cabbage brings a delicious flavor and helps the salsa hold together nicely for scooping with your favorite chips. The result is a fresh, tasty salsa that goes great with guacamole.
    Ingredients:
    3 cups ripe fresh tomatoes, diced 1 cup shredded green cabbage ½ cup diced yellow onion ¼ cup chopped fresh cilantro 1 jalapeno, seeded 1 Serrano pepper, seeded 2 tablespoons lemon juice 2 tablespoons red wine vinegar 2 garlic cloves, minced salt to taste black pepper, to taste Directions:
    Purée all ingredients together in a blender.
    Cover and refrigerate for at least 1 hour. 
    Adjust seasoning with salt and pepper, as desired. 
    Serve is a bowl with tortilla chips and guacamole.

    Dr. Ron Hoggan, Ed.D.
    Celiac.com 06/15/2018 - There seems to be widespread agreement in the published medical research reports that stuttering is driven by abnormalities in the brain. Sometimes these are the result of brain injuries resulting from a stroke. Other types of brain injuries can also result in stuttering. Patients with Parkinson’s disease who were treated with stimulation of the subthalamic nucleus, an area of the brain that regulates some motor functions, experienced a return or worsening of stuttering that improved when the stimulation was turned off (1). Similarly, stroke has also been reported in association with acquired stuttering (2). While there are some reports of psychological mechanisms underlying stuttering, a majority of reports seem to favor altered brain morphology and/or function as the root of stuttering (3). Reports of structural differences between the brain hemispheres that are absent in those who do not stutter are also common (4). About 5% of children stutter, beginning sometime around age 3, during the phase of speech acquisition. However, about 75% of these cases resolve without intervention, before reaching their teens (5). Some cases of aphasia, a loss of speech production or understanding, have been reported in association with damage or changes to one or more of the language centers of the brain (6). Stuttering may sometimes arise from changes or damage to these same language centers (7). Thus, many stutterers have abnormalities in the same regions of the brain similar to those seen in aphasia.
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    Whatever the reason that stuttering has not been reported in the medical literature in association with gluten ingestion, a number of personal disclosures and comments suggesting a connection between gluten and stuttering can be found on the Internet. Abid Hussain, in an article about food allergy and stuttering said: “The most common food allergy prevalent in stutterers is that of gluten which has been found to aggravate the stutter” (10). Similarly, Craig Forsythe posted an article that includes five cases of self-reporting individuals who believe that their stuttering is or was connected to gluten, one of whom also experiences stuttering from foods containing yeast (11). The same site contains one report of a stutterer who has had no relief despite following a gluten free diet for 20 years (11). Another stutterer, Jay88, reports the complete disappearance of her/his stammer on a gluten free diet (12). Doubtless there are many more such anecdotes to be found on the Internet* but we have to question them, exercising more skepticism than we might when reading similar claims in a peer reviewed scientific or medical journal.
    There are many reports in such journals connecting brain and neurological ailments with gluten, so it is not much of a stretch, on that basis alone, to suspect that stuttering may be a symptom of the gluten syndrome. Rodney Ford has even characterized celiac disease as an ailment that may begin through gluten-induced neurological damage (13) and Marios Hadjivassiliou and his group of neurologists and neurological investigators have devoted considerable time and effort to research that reveals gluten as an important factor in a majority of neurological diseases of unknown origin (14) which, as I have pointed out previously, includes most neurological ailments.
    My own experience with stuttering is limited. I stuttered as a child when I became nervous, upset, or self-conscious. Although I have been gluten free for many years, I haven’t noticed any impact on my inclination to stutter when upset. I don’t know if they are related, but I have also had challenges with speaking when distressed and I have noticed a substantial improvement in this area since removing gluten from my diet. Nonetheless, I have long wondered if there is a connection between gluten consumption and stuttering. Having done the research for this article, I would now encourage stutterers to try a gluten free diet for six months to see if it will reduce or eliminate their stutter. Meanwhile, I hope that some investigator out there will research this matter, publish her findings, and start the ball rolling toward getting some definitive answers to this question.
    Sources:
    1. Toft M, Dietrichs E. Aggravated stuttering following subthalamic deep brain stimulation in Parkinson’s disease--two cases. BMC Neurol. 2011 Apr 8;11:44.
    2. Tani T, Sakai Y. Stuttering after right cerebellar infarction: a case study. J Fluency Disord. 2010 Jun;35(2):141-5. Epub 2010 Mar 15.
    3. Lundgren K, Helm-Estabrooks N, Klein R. Stuttering Following Acquired Brain Damage: A Review of the Literature. J Neurolinguistics. 2010 Sep 1;23(5):447-454.
    4. Jäncke L, Hänggi J, Steinmetz H. Morphological brain differences between adult stutterers and non-stutterers. BMC Neurol. 2004 Dec 10;4(1):23.
    5. Kell CA, Neumann K, von Kriegstein K, Posenenske C, von Gudenberg AW, Euler H, Giraud AL. How the brain repairs stuttering. Brain. 2009 Oct;132(Pt 10):2747-60. Epub 2009 Aug 26.
    6. Galantucci S, Tartaglia MC, Wilson SM, Henry ML, Filippi M, Agosta F, Dronkers NF, Henry RG, Ogar JM, Miller BL, Gorno-Tempini ML. White matter damage in primary progressive aphasias: a diffusion tensor tractography study. Brain. 2011 Jun 11.
    7. Lundgren K, Helm-Estabrooks N, Klein R. Stuttering Following Acquired Brain Damage: A Review of the Literature. J Neurolinguistics. 2010 Sep 1;23(5):447-454.
    8. [No authors listed] Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 43-1988. A 52-year-old man with persistent watery diarrhea and aphasia. N Engl J Med. 1988 Oct 27;319(17):1139-48
    9. Molteni N, Bardella MT, Baldassarri AR, Bianchi PA. Celiac disease associated with epilepsy and intracranial calcifications: report of two patients. Am J Gastroenterol. 1988 Sep;83(9):992-4.
    10. http://ezinearticles.com/?Food-Allergy-and-Stuttering-Link&id=1235725 
    11. http://www.craig.copperleife.com/health/stuttering_allergies.htm 
    12. https://www.celiac.com/forums/topic/73362-any-help-is-appreciated/
    13. Ford RP. The gluten syndrome: a neurological disease. Med Hypotheses. 2009 Sep;73(3):438-40. Epub 2009 Apr 29.
    14. Hadjivassiliou M, Gibson A, Davies-Jones GA, Lobo AJ, Stephenson TJ, Milford-Ward A. Does cryptic gluten sensitivity play a part in neurological illness? Lancet. 1996 Feb 10;347(8998):369-71.

    Jefferson Adams
    Celiac.com 06/14/2018 - Refractory celiac disease type II (RCDII) is a rare complication of celiac disease that has high death rates. To diagnose RCDII, doctors identify a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs). 
    However, researchers really don’t have much data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. Such data could provide useful comparison information for patients with RCDII, among other things.
    To that end, a research team recently set out to try to get some information about the frequency and importance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII. The research team included Shafinaz Hussein, Tatyana Gindin, Stephen M Lagana, Carolina Arguelles-Grande, Suneeta Krishnareddy, Bachir Alobeid, Suzanne K Lewis, Mahesh M Mansukhani, Peter H R Green, and Govind Bhagat.
    They are variously affiliated with the Department of Pathology and Cell Biology, and the Department of Medicine at the Celiac Disease Center, New York Presbyterian Hospital/Columbia University Medical Center, New York, USA. Their team analyzed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active celiac disease, 172 celiac disease on gluten-free diet, 33 RCDI, and three RCDII patients and 14 patients without celiac disease. 
    Clonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.
    The team divided the TCR-GR patterns into clonal, polyclonal and prominent clonal peaks (PCPs), and correlated these patterns with clinical and pathological features. In all, they detected clonal TCR-GR products in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with gluten-free diet. They found PCPs in all disease phases, but saw no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). 
    They also noted a higher frequency of surface CD3(−) IELs in cases with clonal TCR-GR, but the PCP pattern showed no associations with any clinical or pathological feature. 
    Repeat biopsy showed that the clonal or PCP pattern persisted for up to 2 years with no evidence of RCDII. The study indicates that better understanding of clonal T cell receptor gene rearrangements may help researchers improve refractory celiac diagnosis. 
    Source:
    Journal of Clinical Pathologyhttp://dx.doi.org/10.1136/jclinpath-2018-205023

    Jefferson Adams
    Celiac.com 06/13/2018 - There have been numerous reports that olmesartan, aka Benicar, seems to trigger sprue‐like enteropathy in many patients, but so far, studies have produced mixed results, and there really hasn’t been a rigorous study of the issue. A team of researchers recently set out to assess whether olmesartan is associated with a higher rate of enteropathy compared with other angiotensin II receptor blockers (ARBs).
    The research team included Y.‐H. Dong; Y. Jin; TN Tsacogianis; M He; PH Hsieh; and JJ Gagne. They are variously affiliated with the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School in Boston, MA, USA; the Faculty of Pharmacy, School of Pharmaceutical Science at National Yang‐Ming University in Taipei, Taiwan; and the Department of Hepato‐Gastroenterology, Chi Mei Medical Center in Tainan, Taiwan.
    To get solid data on the issue, the team conducted a cohort study among ARB initiators in 5 US claims databases covering numerous health insurers. They used Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for enteropathy‐related outcomes, including celiac disease, malabsorption, concomitant diagnoses of diarrhea and weight loss, and non‐infectious enteropathy. In all, they found nearly two million eligible patients. 
    They then assessed those patients and compared the results for olmesartan initiators to initiators of other ARBs after propensity score (PS) matching. They found unadjusted incidence rates of 0.82, 1.41, 1.66 and 29.20 per 1,000 person‐years for celiac disease, malabsorption, concomitant diagnoses of diarrhea and weight loss, and non‐infectious enteropathy respectively. 
    After PS matching comparing olmesartan to other ARBs, hazard ratios were 1.21 (95% CI, 1.05‐1.40), 1.00 (95% CI, 0.88‐1.13), 1.22 (95% CI, 1.10‐1.36) and 1.04 (95% CI, 1.01‐1.07) for each outcome. Patients aged 65 years and older showed greater hazard ratios for celiac disease, as did patients receiving treatment for more than 1 year, and patients receiving higher cumulative olmesartan doses.
    This is the first comprehensive multi‐database study to document a higher rate of enteropathy in olmesartan initiators as compared to initiators of other ARBs, though absolute rates were low for both groups.
    Source:
    Alimentary Pharmacology & Therapeutics