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  • Jefferson Adams
    Jefferson Adams
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    Can Celiac Disease Impair Drug Therapy in Patients?

      Can celiac disease interfere with various types of drug therapies?

    Caption: Photo: CC--Cody Jung

    Celiac.com 04/27/2017 - Celiac disease is associated with numerous chronic conditions, such as anemia and malabsorption of some critical vitamins. Changes in the gastrointestinal tract, rates of gastric emptying, and gastric pH are responsible for impaired vitamin and mineral absorption.

    Intestinal CYP3A4 levels may also be disrupted, which may have implications in first-pass metabolism for some drugs that are substrates for this drug metabolizing enzyme.

    This has led some researcher to investigate the potential impact of celiac disease on drug absorption. This would be of interest to pharmacists, since altered drug absorption can have pharmacokinetic consequences, along with the potential to impact overall drug therapy.

    A comprehensive review on this topic was published in 2013 by Tran et al. Another review was published in 2014. The review by Tran, et al., considered absorption studies in subjects with celiac disease, and the authors focused on a handful of drugs, including acetaminophen, aspirin, propranolol, levothyroxine, methyldopa, and some antibiotics.

    They reported that some reports show an altered gastrointestinal environment and sharp differences between drug absorption in patients with celiac disease, while other reports showed no absorption differences between those with and without the disease. The authors concluded that the drugs could potentially alter absorption in celiac patients, and that healthcare professionals should bear that in mind when starting drug therapy.

    The 2014 review of the potential impact of celiac disease on cardiovascular drug absorption considered many of the same medications previously explored by Tran et al, with a focus on cardiovascular agents. The authors warned that numerous cardiovascular drugs may alter absorption in celiac disease, but noted few published studies with strong, comprehensive data. The authors also stressed the need for more studies on celiac patients, as well as caution when initiating cardiovascular drug treatments.

    Available research indicates that patients with celiac disease can have altered absorption of many different drugs. Unfortunately, there still isn't much good data on altered drug absorption and disposition in celiac patients.

    More study will likely help illuminate the influence of celiac disease on drug disposition. The early evidence suggests that celiac disease may alter drug absorption, but studies don't yet tell us how much, or how often.

    The team is recommending that doctors and pharmacists consider possible absorption issues when prescribing drug treatments for people with celiac disease, and that they review the available literature on specific drugs, when possible. They also recommend increased monitoring for efficacy and adverse effects when beginning a new drug treatment regimen for celiac patients.

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    Interesting topic. The link doesn't clarify if the malabsorption is over or under absorption, or if the subjects were gluten-free. Will watch for more on this topic.

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  • About Me

    Jefferson Adams earned his B.A. and M.F.A. at Arizona State University, and has authored more than 2,000 articles on celiac disease. His coursework includes studies in biology, anatomy, medicine, and science. He previously served as Health News Examiner for Examiner.com, and provided health and medical content for Sharecare.com. Jefferson has spoken about celiac disease to the media, including an appearance on the KQED radio show Forum, and is the editor of the book "Cereal Killers" by Scott Adams and Ron Hoggan, Ed.D.

  • Related Articles

    Dr. Vikki Petersen D.C, C.C.N
    Female Hormones and Autoimmune Disease: The Connection
    This article originally appeared in the Winter 2011 edition of Celiac.com's Journal of Gluten-Sensitivity.
    Celiac.com 08/29/2011 - Nearly 75% of the 24 million Americans suffering from autoimmune disease are women, according to the American Autoimmune Related Diseases Association (AARDA).  Women appear to mount larger inflammatory responses than men when their immune systems are triggered, thereby increasing their risk of autoimmunity.  The fact that sex hormones are involved is indicated by the fact that many autoimmune diseases fluctuate with hormonal changes such as those that occur during pregnancy, during the menstrual cycle, or when using oral contraceptives. A history of pregnancy also appears to increase the risk for autoimmune disease.
    The sex hormone that is commonly low in such women is Dehydroepiandrosterone (DHEA). This is a natural steroid and is produced by the adrenal glands, the reproductive organs and the brain.  DHEA is used by the body to make the male and female hormones, testosterone and estrogen respectively, and is known to have anti-inflammatory effects. It has been proposed that a DHEA deficiency is a contributing factor in autoimmune diseases.  Last year a study was done to look at precisely that effect.  The study’s conclusions have been supported by other, similar research and I think you’ll find it quite interesting.
    The Journal of Clinical Endocrinology & Metabolism Vol. 94, No. 6 2044-2051(2009) published an article entitled “Low Serum Levels of Sex Steroids Are Associated with Disease Characteristics in Primary Sjogren’s Syndrome; Supplementation with Dehydroepiandrosterone Restores the Concentrations”. The authors investigated whether there was a relationship between steroid levels and the disease characteristics of Sjogren’s.
    They based their study on the known data that DHEA not only declines with aging but is reduced in Sjogren’s, an autoimmune disease. The study was populated by 23 post-menopausal women with primary Sjogren’s syndrome and subnormal levels of DHEA. The investigation was a controlled, double blind crossover study, conducted over a 9 month period, where DHEA was assessed by sophisticated laboratory measurements and typical symptoms of Sjogren’s such as dry mouth and eyes and salivary flow rates were similarly assessed.
    Results revealed a strong correlation between low DHEA and Sjogren’s symptoms.  DHEA and its sex hormone metabolites (testosterone and estrogen) were found to increase with DHEA supplementation but not with the placebo. Symptoms such as dry eyes were seen to improve as estrogen levels
    The researchers concluded that the disease manifestations of primary Sjogren’s syndrome were associated with low sex hormone levels and the supplementation of DHEA allowed the body to transform into androgens, testosterone and estrogen, with testosterone production predominating.
    Please allow me to add some personal interpretation. For the most part I agree with the premise and applaud the results. The facts that autoimmune disease occurs more often in women, that women frequently have low DHEA, and that androgens have anti-inflammatory effects that can benefit autoimmune disease are all true.
    But should we simply give such women DHEA and call it a day? I don’t think so.  I propose that we do three things: First, evaluate hormonal levels in women regularly; Second, address WHY their hormonal levels are imbalanced;  And third, when supplementing with hormones such as DHEA, ensure that the delivery system is one that mimics what the body does naturally.
    Remember that autoimmune disease can begin many years before the first symptoms become manifest. Therefore evaluating hormonal levels in our younger women is a good idea.  When I find DHEA levels that are low, my first order of business is to assess why.  Frequently it is due to a phenomenon known as “pregnenelone steal” that occurs when the adrenal glands are under stress.  It is a common occurrence and one of the fantastic abilities of the human body to shift from one pathway to another when under stress.  The “steal” pathway diverts the body away from making sex hormones and instead it makes more “stress” hormones.  So while adding some DHEA into the mix might very well help, does it make sense to find out WHY it’s being diverted away from making sex hormones?  I hope so because it’s the very foundation of the medicine that we practice—functional medicine.
    Once you understand the root cause of the deficiency you can take steps to truly remedy it rather than simply covering it up by taking DHEA.  Not to keep hitting you over the head with this concept, but supplementing with DHEA as your sole treatment misses the underlying cause since the body is designed to make adequate quantities of DHEA.
    A common reason for the diversion or “steal” pathway to become activated is adrenal stress from poor absorption of nutrients, unstable blood sugar and the presence of infections—all problems we see with the gluten intolerant patient! While I’m not implying that every autoimmune patient has a gluten intolerance, it certainly warrants screening all of them because of its high prevalence.
    As we travel down the road to optimal health through avoiding any food the body isn’t tolerating well, improving the integrity of the small intestine and normalizing adrenal function, there are certainly times when hormonal supplementation is beneficial. I don’t recommend the oral route because the first place the hormone travels is to the liver and this can be burdensome to that organ.  When the body makes hormones naturally it delivers them straight to the bloodstream.  In an effort to mimic that delivery system we use a buccal route (placed between cheek and gum in the mouth) that does a good job in bringing the hormone directly to the bloodstream and bypassing the liver and digestive tract.
    Autoimmune diseases comprise the third leading cause of death in our country and research strongly suggests that its rapid increase is due to environmental factors, especially those that weaken the small intestine. I am committed to earlier diagnosis while the disease is still remediable, as well as overall reduction of incidence through addressing digestive health.
    I hope you find this informative.  Please share this information with those who have autoimmune disease themselves as well as in their family.


    Jefferson Adams
    Celiac.com 09/30/2013 - The negative impact of celiac disease on the sexual health of celiac sufferers is one of the great undiscussed aspects of the disease, according to Phil Zimbardo, a prominent psychologist and professor emeritus at Stanford University in California.
    “No one talks about the sex part in celiac disease,” Zimbardo says, no one tells people that celiac disease can destroy their sex drive and challenge "their very manhood." This and other of Zimbardo's views on celiac disease and its impact on sexual health can be found in an excellent article by Lisa Fitterman in Allergicliving.com.
    For Zimbardo, life before his celiac diagnosis was a dark place. As his body suffered the effects of celiac disease, Zimbardo grew so depressed that he lost all interest in sex and intimacy. This, in turn, had a negative impact upon Zimbardo's marriage.
    This negative impact of celiac disease on sexual health is not unique to men. Many woman with celiac disease see their own sex lives suffer.
    In the case of Alice Bast, founder and president of the National Foundation for Celiac Awareness (NFCA), celiac disease had a number of adverse effects on her health and well-being.
    Bast acknowledges to Fetterman that symptoms of undiagnosed celiac disease pushed sex far from her mind, and that her libido did not make a miraculous return upon diagnosis and going gluten-free. Even after she was diagnosed, her physical recovery was slow, due to chronic malnourishment that contributed to multiple miscarriages and a stillbirth. In fact, when it came to sex, Bast says that the return of her sexual health came slowly, almost imperceptibly, until she realized that she was enjoying intimacy again after years of avoiding it.
    Echoing Bast's experience, Zimbardo points out that, "as a psychologist, I’m always analyzing behavior and I just couldn’t understand what has happening to me until I was diagnosed.”
    Once he was diagnosed, however, Zimbardo cut gluten from his diet and started taking anti-inflammatories and probiotics to regrow his gut flora. It took a full year for his gut to heal and for his full health and vigor to return, but now he is healthy, both physically and sexually.
    For Zimbardo, and many others, giving up the gluten is the key to returning to good health, and healthy sexual activity. Giving up gluten was "nothing short of transformative.” Now, he says he "can’t wait to be 80."
    There is a great deal of anecdotal information to suggest that celiac disease can have adverse impacts on sexual health, yet very little actual data exists. It will be interesting to see if and when researchers begin to look for answers. 

    Jefferson Adams
    Does Benicar Trigger Celiac-like Gut Symptoms?
    Celiac.com 07/09/2014 - Does the blood pressure medication Benicar (Olmesartan medoxomil) trigger celiac-like gut symptoms?
    The law firm Levin, Papantonio has filed a lawsuit claiming just that, on behalf of a Texas man who allegedly developed a rare gastrointestinal condition known as sprue-like enteropathy while taking Benicar.
    According to the complaint, Benicar caused the plaintiff to suffer severe gastrointestinal symptoms, including chronic diarrhea, weight loss, malnutrition, and dehydration. These symptoms are commonly associated with a rare sprue-like enteropathy.
    The lawsuit comes as Benicar faces scrutiny following a Mayo Clinic study linking the popular drug to rare sprue-like enteropathy in users.
    The connection between Benicar and the sprue-like enteropathy symptoms was first noted by Mayo Clinic gastroenterologist, Dr. Joseph Murray, after he observed two patients taking Benicar experience relief from symptoms thought to be associated with Celiac disease. Upon discontinuing the use of Benicar, the gastrointestinal symptoms vanished.
    Dr. Murray then conducted a three-year study of 22 people who experienced celiac-like symptoms while taking Benicar. He found that 14 of those patients had symptoms so severe that hospitalization was required.
    Moreover, none of the 22 original patients responded to a gluten-free diet, and none showed any detectable levels of tissue transglutaminase in the blood, which would point to celiac disease.
    After discontinuing the Benicar treatments, the intestinal symptoms disappeared in each of the 22 patients, and they all regained lost weight.
    In 2013, in keeping with Dr. Murray’s findings, the U.S. Food and Drug Administration changed Benicar’s label to include a warning that the drug may trigger sprue-like enteropathy and symptoms similar to celiac disease.
    If you think you may have suffered adverse effects from Benicar, check with your doctor, and possibly with a lawyer.
    Sources:
    Mayo Clinic: Study on Benicar and sprue-like enteropathy FDA Safety Communication Concerning Label Change on Benicar, 2013. digitaljournal.com.

    Jefferson Adams
    Why All the Hate for Celiac Disease Drug Treatments?
    Celiac.com 09/18/2015 - That old saw about death and taxes might need a bit of amending to include complaints about pharmaceutical companies working on celiac drug treatments.
    One interesting facet of our coverage of the development of various drugs to treat and/or cure celiac disease has been the regular presence of comments questioning the motives,and actions of the companies involved.
    It's funny, but no one complains that companies still make money selling aspirin, and that no one has cured a headache, and that there must be some conspiracy to profit off of those who suffer a headache.
    There's no doubt that there's money to be made producing drugs that treat disease. But, if a company can develop and produce a safe drug to protect celiacs against contamination, or to help reduce symptoms, what's wrong with that?
    Just like an aspirin, I can take it or not take it.
    In the old days, ten years ago or more, people with celiac disease generally suffered in silence, with scant gluten-free food choices, and little information. However, in just a decade, we've got a wealth of information, and multi-billion dollar gluten-free foods market and a number of companies developing drugs to treat or cure celiac disease.
    To me, that's a good thing. Still, there are naysayers. Here's a rundown of comments by readers who seem less than enthused about celiac drugs in development.
    Our recent article, An Update on Every Celiac Disease Drug Currently in Development included the comment:
    "Article's fine. Concept's disturbing. Eating a gluten-free diet is the free, already-proven cure for celiac and gluten-intolerance. They don't have to torture mice and likely other animals to find a 'cure' for something that there already is a cure for. I imagine there is $$ for the researchers here and $$ for the animal labs and $$ for the pharmaceuticals."
    Of our article entitled, How Close Are New Celiac Disease Treatments? one reader wrote:
    "I would be very cautious about taking any of these until it was proven absolutely to have no side effects. There always are some and history has shown some to be deadly." Commenting on our article ALV003 Reduces Gluten Damage in Celiac Disease Patients, one reader commented:
    "I only want to know: how long until random internal organs begin to fail or malfunction as a result of yet another new mystery drug? I'd rather starve to death than be a guinea pig for big pharma again."
    Our article on NexVaxx, entitled Is a Vaccine for Celiac Disease Just Around the Corner? included the following comments:
    "Totally agree with vhill seems like a ploy to poison people with GMO foods that come up with a supposed "'cure'. Eat healthy whole foods this is not a curse its a wake up call to be healthy if you didn't have celiac you'd probably be eating processed crap." Balm wrote: "Thanks but no thanks. I'll remain a celiac and continue to eat healthy. While trying to fix one problem, some will end up with far worse problems." Jonnys wrote: "Stupid idea! Just another way to make more money off of people." These are but a few of the largely positive comments we receive, and we hope you enjoyed them as much as we do.

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    Got the result today, and it is indeed the IgG only, and it is "negative" with a result of: <10.0 Units I have sent a message to my doctor requesting that she at least also order the TTG IGA test. However, I'm assuming that this result does at least significantly lower the likelihood that I have celiac? This is all just a shot in the dark anyhow... but after 8 years of unsatisfactorily diagnosed mystery joint pain, I don't want to only half-explore an option and then abandon it without a reasonably definitive result.
    It sounds like you were not given the full celiac panel. The full celiac panel includes: TTG IGA
    TTG IGG
    DGP IGA
    DGP IGG
    EMA
    IGA You have to be eating gluten daily for 12 weeks before the blood test. A positive on any one blood test should lead to a gastroenterologist doing an endoscopy /biopsies to confirm a celiac diagnosis.    
    Yep, dang just realized I had a $10 off code in my email for the coffee you could have used. Yeah I love the coffees, some are odd. Most dessert ones require you to sweeten to bring it out, some you only taste cold. They are fun to play with and I love how they give me enjoyment when it comes to food.
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