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    Do Adult Celiacs with Pancreatic Insufficiency Require Long-Term Enzyme Supplements?


    Jefferson Adams
    Image Caption: New research on pancreatic insufficiency and celiac disease.

    Celiac.com 06/18/2010 - One of the conditions associated with celiac disease is called exocrine pancreatic insufficiency. A previous study showed that exocrine pancreatic insufficiency is the trigger for about one in three (20/66) cases of current or persistent diarrhea in adults with celiac disease. Of these 20 patients, 19 showed initial improvement with pancreatic supplementation.


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    However, at this point, there are no longitudinal studies on exocrine pancreatic insufficiency in the medical literature. A research team set out to rectify that by conducting their own longitudinal study. The team included Kate E. Evans, John S. Leeds, Stephen Morley, and David S. Sanders.

    Over the next four years, the team conducted prospective follow-up checks on the 20 patients who received therapy for exocrine pancreatic insufficiency. The team assessed gastrointestinal symptoms, dietary adherence, celiac antibody status, and dose of enzyme supplementation. They repeated titters for fecal elastase-1 (Fel-1) to reassess exocrine pancreatic function.

    The team was able to review 19 of the 20 patients; one patient had died. The group averaged 59.7 years of age. Seven subjects were male. On average, patients suffered from celiac disease for 13.2 years.

    Eleven out of nineteen patients continued on enzyme supplementation, with average doses of 45,000 units of lipase per day. Only one of the eleven patients reported no reduction in symptoms, while eight of the 19 patients had discontinued the supplements after their diarrhea abated.

    The entire group showed a substantial increase in Fel-1 levels over time, with median values of 90 lg/g at zero months, 212 lg/g at six months, and 365 lg/g at follow-up of 45–66 months (p/0.0001).

    Fecal elastase-1 is helpful in spotting exocrine pancreatic insufficiency in adult celiac patients with diarrhea.

    Results of the team's longitudinal survey indicate that that patients with celiac disease can end pancreatic enzyme supplementation as symptoms improve.

    Source:

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  • Related Articles

    Scott Adams
    Dig Dis Sci 2000;45:403-406.
    (Celiac.com 04/10/2000) Italian researcher Dr. Tarcisio Not, of Clinica Pediatrica, I.R.C.C.S., Trieste, and colleagues, have concluded that a relatively high percentage of patients with autoimmune thyroiditis also have celiac disease. They studied 172 patients who had autoimmune thyroid disorders, and two control groups. Their control groups were comprised of 498 patients with other diseases, and 4,000 healthy patients. The method used by the researchers was a blood test that looks for IgA-class endomysium antibodies using immunofluorescence.
    Their results, which were published in the February issue of Digestive Diseases and Sciences, show that the prevalence of celiac disease is 3.4% in patients with autoimmune thyroiditis, compared with 0.6% and 0.25% among the two control groups. They also found a connection between untreated celiac disease, gluten consumption, and autoimmune disorders. The researchers believe that undiagnosed celiac disease can cause other disorders by switching on some as yet unknown immunological mechanism. Untreated celiac patients produce organ-specific autoantibodies. Further, By following these subjects longitudinally, it has been seen that not only do the anti-gliadin antibodies and anti-endomysium antibodies disappear after 3 to 6 months of a gluten-free diet, but so do the organ-specific autoantibodies.
    In conclusion the Italian researchers suggest that patients with autoimmune thyroiditis could benefit from a screening for celiac disease, which could eliminate the symptoms and limit the risk of developing other autoimmune disorders.

    Jefferson Adams
    Celiac.com 04/23/2007 - The results of a recent Dutch study published in the World Journal of Gastroenterology have confirmed a connection between Hashimotos Thyroiditis and celiac disease. In the study, 104 individuals with Hashimotos Thyroiditis were tested for immunoglobulin A anti-transglutaminase (tTG) antibodies, IgA anti-endomysial antibodies (EMA) and HLA-DQ typing. Those who tested positive for any of the serological tests were given an intestinal biopsy.
    Sixteen patients (15%) showed positive celiac serology and five patients clear villous atrophy were diagnosed with celiac disease (4.8%; 95% CI 0.7-8.9). All five patients diagnosed with celiac disease, and 53 patients with Hashimotos thyroiditis (50%; 95% CI 43-62), showed the presence of HLA-DQ2 (and/or -DQ8).
    In a separate test within the study, 184 Individuals with known celiac disease were given a serological test for thyroglobulin and thyroid peroxidase Antibodies, after first being given thyroid biochemical, a thyroxine-free thyroid stimulating hormone.
    39 patients (21%) showed positive thyroid serology. According to thyroid biochemistry results, ten patients showed euthyroidism (5%; 95% CI 2-9), seven showed sub-clinical hypothyroidism (3.8%; 95% CI 1.8-7.6), and 22 patients showed overt hypothyroidism, Hashimotos thyroiditis (12%; 95% CI 8-16). Furthermore, four patients with celiac disease had Graves disease (2%; 95% CI 0.8-5) and one patient had post-partum thyroiditis.

    The study concludes that there is a clear association between Hashimotos thyroiditis and celiac disease. Accordingly, it is recommended that patients with Hashimotos thyroiditis be screened for celiac disease and that patients with known celiac be screened for Hashimotos thyroiditis.
    World Journal of Gastroenterology 2007; 13(10).
    health writer who lives in San Francisco and is a frequent author of articles for Celiac.com.

    Jefferson Adams
    Celiac.com 11/25/2008 - Celiac disease is one of the most under-diagnosed medical disorders, with 97% of all cases currently remaining undiagnosed. According to the National Institutes of Health, 3 million people in theUnited States with celiac disease, while only 140,000 have beendiagnosed. Celiac disease ismore than twice as common in people over 50 years of age.
    People with untreated celiac disease are at risk of developing anynumber of associated conditions, including gastrointestinal cancer atrates of 40 to 100 times those of the general population, in additionto osteoporosis, and a two-fold increase in the risk of fractures,including first-time hip fractures. Moreover, an unusually highpercentage of people with celiac disease suffer from the followingconditions: Anemia, Arthritis, Ataxia, Cancer—Non-Hodgkin’s Lymphoma, Cow's Milk Intolerance, Dermatitis, Diabetes-Type 1, Irritable Bowel Syndrome, Liver Disease, Migraine Headaches, Nerve Diseaseand/or Peripheral Neuropathy, Obesity, Osteoporosis,Osteomalacia/Low Bone Density, Pancreatic & Thyroid Disorders.
    According to a new study by doctors based in Sweden, people with celiac disease face a significantly higher risk of developing thyroid disorders, including hypothyroidism, hyperthyroidism and thyroiditis.
    The thyroid is a small, butterfly-shaped gland in the neck that creates the hormones that control human metabolism.  People with under-active thyroid, called hypothyroidism, suffer symptoms such as fatigue, sensitivity to cold, dry skin and weight gain, while people with overactive thyroid, called hyperthyroidism, commonly suffer from symptoms such as excessive sweating, heat intolerance, and nervousness. However, mild cases of hypo- or hyperthyroidism commonly present no symptoms at all. Inflammation of the thyroid gland is called Thyroiditis.
    The research team, led by Dr. Peter Elfstrom at Orebro University Hospital, reviewed Swedish national health records covering the period from 1963 to 2003. The team compared rates of thyroid disease for 14,000 people with celiac disease against some 68,000 non-celiac control subjects matched for age and gender.
    The results showed that people with celiac disease are diagnosed with hypothyroidism more than four times as often as non-celiacs, with hyperthyroidism more than three times as often as non-celiacs, and with hyperthyroidism more than 3.6 times as often as non-celiacs. Moreover, the relationship works both ways: people with established hypothyroidism, hyperthyroidism and thyroiditis face much higher rates of celiac disease.
    These results held true even after the data were adjusted for potential confounders, including the presence of diabetes mellitus. The researchers theorize that the association between celiac disease and thyroid disease may be due to shared genetic or immunological traits.
    This is just the latest in a string of studies that drives home the importance of early testing for suspected celiac cases, as early discovery and treatment with a gluten free diet greatly reduces associated complications in celiac disease.
    Journal of Clinical Endocrinology and Metabolism, October 2008.

    Jefferson Adams
    Celiac.com 03/03/2010 - A team of researchers set out to assess long-term outcomes of thyroid function and autoimmunity in a large population of children with celiac disease.
    The research team included Alessandra Cassio, MD, Giampaolo Ricci, MD, Federico Baronio, MD, Angela Miniaci, MD, Milva Bal, MD, Barbara Bigucci, MD, Veronica Conti, MD, and Alessandro Cicognani, MD.
    To accomplish this, they conducted a longitudinal, retrospective study at the Pediatric Department, University of Bologna, Italy (duration of follow-up, 8.9 +- 4.0 years).
    In all, the team examined one hundred thirty-five consecutive patients diagnosed between June 1990 and December 2004 and followed on a gluten-free diet.
    To be included, researchers required study subjects to maintain good dietary compliance and duration of follow-up for at least 3 years. A total of 101 patients showed no positive antithyroid titers during the follow-up, while 86 remained euthyroid; 15 showed high thyroid-stimulating hormone values at diagnosis that normalized in 11 cases after 12 to 18 months of gluten withdrawal. A total of 31 patients showed persistently positive antibody titers, with 23 of those (74%) remained consistently euthyroid during the follow-up and 8 (26%) had a subclinical hypothyroidism.
    Children with growth retardation or gastroenterological symptoms at diagnosis and different lengths of gluten exposure showed similar rates of positive antibodies.
    In children with celiac disease, antithyroid antibodies have a low clinical value for predicting the development of thyroid hypo-function during the indicated surveillance period. They encourage a more comprehensive follow-up.
    Source:
    J Pediatr. Volume 156, Issue 2, Page A2; February 2010


  • 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. 
    The team cross-referenced each article with the words ‘Asia,’ ‘Europe,’ ‘Africa,’ ‘South America,’ ‘North America,’ and ‘Australia.’ They defined celiac diagnosis based on European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines. The team used 96 articles of 3,843 articles in their final analysis.
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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.
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    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.
    So how, you may ask, is all this related to gluten? As a starting point, one report from the medical literature identifies a patient who developed aphasia after admission for severe diarrhea. By the time celiac disease was diagnosed, he had completely lost his faculty of speech. However, his speech and normal bowel function gradually returned after beginning a gluten free diet (8). This finding was so controversial at the time of publication (1988) that the authors chose to remain anonymous. Nonetheless, it is a valuable clue that suggests gluten as a factor in compromised speech production. At about the same time (late 1980’s) reports of connections between untreated celiac disease and seizures/epilepsy were emerging in the medical literature (9).
    With the advent of the Internet a whole new field of anecdotal information was emerging, connecting a variety of neurological symptoms to celiac disease. While many medical practitioners and researchers were casting aspersions on these assertions, a select few chose to explore such claims using scientific research designs and methods. While connections between stuttering and gluten consumption seem to have been overlooked by the medical research community, there is a rich literature on the Internet that cries out for more structured investigation of this connection. Conversely, perhaps a publication bias of the peer review process excludes work that explores this connection.
    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