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      Frequently Asked Questions About Celiac Disease   04/07/2018

      This Celiac.com FAQ on celiac disease will guide you to all of the basic information you will need to know about the disease, its diagnosis, testing methods, a gluten-free diet, etc.   Subscribe to Celiac.com's FREE weekly eNewsletter   What are the major symptoms of celiac disease? Celiac Disease Symptoms What testing is available for celiac disease?  Celiac Disease Screening Interpretation of Celiac Disease Blood Test Results Can I be tested even though I am eating gluten free? How long must gluten be taken for the serological tests to be meaningful? The Gluten-Free Diet 101 - A Beginner's Guide to Going Gluten-Free Is celiac inherited? Should my children be tested? Ten Facts About Celiac Disease Genetic Testing Is there a link between celiac and other autoimmune diseases? Celiac Disease Research: Associated Diseases and Disorders Is there a list of gluten foods to avoid? Unsafe Gluten-Free Food List (Unsafe Ingredients) Is there a list of gluten free foods? Safe Gluten-Free Food List (Safe Ingredients) Gluten-Free Alcoholic Beverages Distilled Spirits (Grain Alcohols) and Vinegar: Are they Gluten-Free? Where does gluten hide? Additional Things to Beware of to Maintain a 100% Gluten-Free Diet What if my doctor won't listen to me? An Open Letter to Skeptical Health Care Practitioners Gluten-Free recipes: Gluten-Free Recipes
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Erin80

Gluten And My Depression Experience

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Hi, everyone! I am new here. I have been a different person mentally and physically I believe simply because I consumed gluten. Whole grains are supposed to be good for you, right? What a scam.

I have had digestive issues for as long as I can remember. I am 32 years old. I have always been bloated, grouchy, extremely fatigued all day long, unable to function in social situations, unable to make new friendships, irritable, and the list goes on. I don't know why I didn't think to cut out gluten before. My mom was tested recently for food sensitivities and was sensitive to gluten. I decided to stop eating it three days ago and feel better than I have my entire life! I am elated and have new hope for myself and my future. I cannot express how grateful I am to finally have an answer.

I have been diagnosed with depression, bipolar, anxiety, delayed phase sleep disorder, and was given medications for these illnesses. All the pills did was drive me crazy (crazier than I already felt). I wish I had known that my behavioral and physical issues were related to consumption of gluten. I really messed up my life in a lot of ways due to feeling bad all the time. So I felt depressed and continued scarfing bread and pasta. The question is, which came first, the depression or the gluten intolerance...

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Since by nature I am neither depressive nor do I have any clinical psychological or mental health issues (or so I am told),

I was perplexed and frustrated and damn scared when I fell into depressive thinking and developed anxiety and had bouts of real fear and frantic or obsessive thinking. I was an insomniac to the point of real sleep deprivation and had a sleep study done. This went on for 3 years --along with many other symptoms---before my DX.

It was the celiac. I call it "Gluten head" and I was very ill and had cognitive issues and ataxia as well. It affected my brain in various ways.

I have NONE of these symptoms now that my gut is healing and I have been gluten-free for 18 months. I am "me" again. :)

There are many medical articles written about this correlation between gluten, celiac and depression, arising from nutritional deficiencies, the effect of malabsorption on amino acids and neurotransmitters, etc.

You may find these articles of interest. Go to this site and look on the right hand side for articles related to psych issues:

http://sites.google.com/site/jccglutenfree/

You may wish to remain on gluten and have a celiac panel done.

The test will not be valid if you are not actively consuming gluten. Since you feel markedly better off it, I am thinking you are gluten sensitive at least, but you may want to cover your bases and see if celiac is the underlying cause.

I know at least one member on here whose bipolar symptoms are resolved. (I am sure there are others) Maybe she will see this and post.

Best wishes to you!

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My worst symptom is anxiety. It built up and built up until I had what I assume is a nervous breakdown even though I don't know for sure. I had this sense of doom that I was going to die. I focused on it day and night and was scared to fall asleep because I thought I wouldn't wake up. Every time I looked at my young kids I would tear up thinking they would grow up without me. When I finally got diagnosed with a gluten allergy in my mind I had brain tumors, diabetes, cancer, heart attacks, you name it I had it. I finally just lost it one day and cried uncontrolably, I was apologizing to my wife for leaving her to raise two young kids without me, and cried when I saw my 5 year old. About 2 weeks after I went gluten free I was laying in bed and just started breathing deeply and realized how calm I was. It never occured to me that my gluten intolerance would cure my anxiety. Most people say that it is due to malabsorption of vitamins, but the weird thing is that if I accidentally gluten myself now, the first symptom I feel is I get really anxious. It will get better, but 1 year later it still isn't perfect. Hang in there.

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My worst symptom is anxiety. It built up and built up until I had what I assume is a nervous breakdown even though I don't know for sure. I had this sense of doom that I was going to die. I focused on it day and night and was scared to fall asleep because I thought I wouldn't wake up. Every time I looked at my young kids I would tear up thinking they would grow up without me. When I finally got diagnosed with a gluten allergy in my mind I had brain tumors, diabetes, cancer, heart attacks, you name it I had it. I finally just lost it one day and cried uncontrolably, I was apologizing to my wife for leaving her to raise two young kids without me, and cried when I saw my 5 year old. About 2 weeks after I went gluten free I was laying in bed and just started breathing deeply and realized how calm I was. It never occured to me that my gluten intolerance would cure my anxiety. Most people say that it is due to malabsorption of vitamins, but the weird thing is that if I accidentally gluten myself now, the first symptom I feel is I get really anxious. It will get better, but 1 year later it still isn't perfect. Hang in there.

what you describe is very similar to what I went through. My anxiety manifested as an intense social anxiet/shyness and I lost alot of weight and would not leave my house except at night. Having never experienced anything like that before, I began to fear that I was dying because I had lost so much weight. I got through the first episode with the use of ssri medication and recovered. but the next episode a year later was as bad and then I was dx'd. The second treatment was prozac and it 's what saved me. I felt completely normal after taking it a few weeks.

The problem now is that since I don't take the ssri to boost my serotonin, I still struggle in the mornings; getting going, feeling happy to face the world. Its still not easy even though I am gluten free. could it be that I was exposed to gluten for my whole life that the serotonin deficit might always be a problem? any thoughts or comment are greatly encouraged and appreciated...

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I believe that my biggest symptom is anxiety, just like the other posters on this thread. I have been an anxious and worried personality my whole life, but I had gotten it under control and was really doiing well, emotionally and mentally. Then about two years ago I started to feel not quite right, after 6-8 months it developed into a full blown panic/anixety disorder, then it got even worse, and then about 8 months ago I was finally tested for celiac.

It has been 5 months since i started the diet and I have to say that I am feeling quite a bit better, and the anxiety level has gone down from an 11 to maybe a 5-6, but it is still somewhat high. I would love to get it back down to a 2 or 3 (which i feel would be a normal amount, like when I was in good shape a few years ago).

I have to remind myself that this is a major process of healing a very damamged body. It doesn't happen overnight. The problem with an anxiety disorder is that your brain wants to see it fixed right now! if it doesn't get fixed instantly, its just more fodder for the anxiety monster to use against you.

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Welcome Erin!

While I have no idea whether the chicken or the egg came first, I am confident that gluten intolerance / celiac comes before depression and other psychological issues.

It frustrates me to no end that doctors automatically jump to prescribing anti-depressants/mood stabilizers without ever considering food intolerance. Psychological disorders are commonly said to be caused by chemical imbalance - so where is someone supposed to get the neurotransmitters for proper brain function if they are not absorbing essential nutrients from their food in the first place?

It took me decades to figure out that I got depressed after being ill and never got ill because I was depressed! It seems simple but when docs were repeatedly telling me that I was healthy and that my symptoms must be caused by depression, stress, hormones, overworking or simply being a Mom -- eventually part of me believed it...I know that I went several years without going to doctors because I didn't want to hear it - in my gut I knew they were wrong -- and guess what? -- the problem was in my gut all along.

Sorry for the rant, but I know how frustrating it is to know that your life could have taken a different path had you only known that the "healthy" food you were ingesting was causing serious health problems.

I try to focus on the blessings I do have, keep hope for health and all other good things, but some days the frustration cancels all that out.

I am hopeful that you will continue to improve and glad that you found gluten was causing you problems...but please know that it can be a long road to healing so grab onto all the good stuff you can along the way and be good to yourself while you heal.

Hang in there :)

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It took me decades to figure out that I got depressed after being ill and never got ill because I was depressed! It seems simple but when docs were repeatedly telling me that I was healthy and that my symptoms must be caused by depression, stress, hormones, overworking or simply being a Mom -- eventually part of me believed it...I know that I went several years without going to doctors because I didn't want to hear it - in my gut I knew they were wrong -- and guess what? -- the problem was in my gut all along.

This is a great statement. I have been struggling with this a lot. It boils down to the notion of whether or not one believes that the mind can cause such severe psychosomatic pain. I mean, can a fear or worry have such a profound effect on the physical state as to cause damage to the intestines and make us feel all the symptoms of celiac? Or does one believe that the symptoms originate with celiac and the psychological issues are conflated and confused by them?

the theory that the simplest answer is usually the best shows me that it most likely is that celiac is causing the problem, and the psychology is being dragged along for a ride.

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This is a great statement. I have been struggling with this a lot. It boils down to the notion of whether or not one believes that the mind can cause such severe psychosomatic pain. I mean, can a fear or worry have such a profound effect on the physical state as to cause damage to the intestines and make us feel all the symptoms of celiac? Or does one believe that the symptoms originate with celiac and the psychological issues are conflated and confused by them?

the theory that the simplest answer is usually the best shows me that it most likely is that celiac is causing the problem, and the psychology is being dragged along for a ride.

That reminds me of the guff they used to say about stomach ulcers being caused by stress and worry and spicy foods. Totally false as it turns to be a bacteria that causes 90% of them.

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I think you guys might want to walk into a psychiatric ward and ask that question to the residents. Maybe that guy sitting there on the couch? Oh wait, he won't know because he lost most of his memories from ECT. What about that girl in the corner? She looks normal, opps, she still feels the fire burning her from 5 years ago. The list goes on.

Psychiatric disorders have enough stigma attached to them as it is. It is not a "I have Celiac so I got anxiety too"

Celiac and thyroid disease often come together but not always. You still have thyroid disease and still take a med for it. At any rate you don't say, now that I'm celiac everything gets better. But it all doesn't does it?

Mental Illness can be horrific how it presents, or can be abused by a person who has no idea what it is.

Disclaimer: I am not a doctor nor do I portray one in a commercial. I do not intend for you to actually walk in to a psych ward as they may keep you. My intention is never to offend but to inform.

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When i get glutened, I get very gloomy and then will often have times of anxiety and aimless anger and irritability. It is a very strange feeling because I am naturally a really layed back and comical person, yet most of my life people thought I was very negative and introverted. The feelings I get are just that, "feelings". I cannot help it. It is almost extrinsic. Even when I am thinking things are good and I just have more learning to do and it will get better and better and I am proud of my progress, somehow I simultaneously have this gut sickening sadness. I just feel gloomy as if there is no reason in the world to be happy and i get helpless feelings like my "flight" hormones are at full force.

Exercise always helps tremendously for me it doesn't matter if it is walking up and down the stairs or even just stretching.

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Colleen-

I guess I mis-typed as I should have wrote that I believe celiac/gluten MAY come before psychological issues.

Unfortunately, I have had to visit two friends, one sister and one brother-in-law in the psychological hospital over the years. My sister has suffered from major depressive disorder which has nearly taken her life 4 times. Bi-polar did take my brother-in-law (my husband's closest brother, my nephew's dad and my kid's uncle) from us. So when I said in my case I knew in my gut that depression was not causing my physical illness I was talking about what was going on with me - not others that may have depression or other physiological issues.

I in no way intended to dismiss any psychological disorders by my beliefs that the lack of nutrition due to mal-absorption CAN lead to a disruption of the neurotransmitters in the brain OR that being stuck in bed for weeks on end with undiagnosed disease/chronic illness can cause depressed mood.

-Lisa

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Colleen-

I guess I mis-typed as I should have wrote that I believe celiac/gluten MAY come before psychological issues.

Unfortunately, I have had to visit two friends, one sister and one brother-in-law in the psychological hospital over the years. My sister has suffered from major depressive disorder which has nearly taken her life 4 times. Bi-polar did take my brother-in-law (my husband's closest brother, my nephew's dad and my kid's uncle) from us. So when I said in my case I knew in my gut that depression was not causing my physical illness I was talking about what was going on with me - not others that may have depression or other physiological issues.

I in no way intended to dismiss any psychological disorders by my beliefs that the lack of nutrition due to mal-absorption CAN lead to a disruption of the neurotransmitters in the brain OR that being stuck in bed for weeks on end with undiagnosed disease/chronic illness can cause depressed mood.

-Lisa

Hi Lisa,

I promise, I didn't mean to get in anyone's face about this. It's a sensitive issue for me as it sounds like for you too. I can appreciate that.

Sometimes I'll read something to my husband while I'm ranting and he calmly takes my playbook from me. It's okay because I do it to him to lol. I met my husband in a psych ward 5 years ago. I was there for a month after a suicide attempt. I was getting a course of ECT treatments and he was outpatient getting ECT's too. We are quite the pair, as you can imagine.

These issues are very difficult whether it's you, your family or friends.

And now I'm off to scarf down some Betty Crocker Brownies :D

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It is SO relieving to hear about these stories of other celiac/gluten intolerance folks who have also struggled with anxiety. Thank you so much for sharing them!

I remember having anxiety attacks as young as 4 years old, as well as hyperactivity and severe temper tantrums. The doctor suggested it was food-related (yay!) but said the cause was actually food coloring additives. Oh well, at least he was on the right track (back in the mid-80's) which it more than I can say for any doctor since. I wondered for years what was wrong with me, and when I was in high school would check out books from the library on all kinds of mental disorders to try and match symptoms with what I felt.

It started out as social anxiety. I couldn't stand being in public places or around strangers. Then it became intense anxiety over every little thing, along with panic attacks. They were always worse during stressful situations, but would sometimes pop up out of nowhere.

When all the other gluten issues got worse as I got older a doctor told me it was all just an manifestation of anxiety, and mostly in my head. So I asked her what could possibly be causing the anxiety, and she just looked at me funny like "You're not supposed to ask that question" and gave me a Xanax prescription. No effort to find a cause, just a pill.

My husband, who isn't gluten intolerant, was once diagnosed with bipolar disorder because he had been feeling out of sorts. He was put on three medications for it, and was so messed up that he was institutionalized twice attempted suicide once. The pills made him feel MORE depressed and MORE disconnected. He finally stopped taking them, saw another doctor, and was diagnosed with PTSD from childhood trauma instead. He was given a small SSRI dose, and now he feels fine almost all the time. I swear these doctors are guessing 99% of the time. They turned a man with mild psychiatric problems into a total wreck.

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I can really appreciate this post from all angles, as I have Celiac (obviously), have struggled with mild anxiety for most of my adolescence and young adult life, and ironically enough am a mental health therapist for children and adolescents. Its interesting, when we're in school doing our clinical training, they ALWAYS teach you that the FIRST rule of diagnosing is RULE OUT MEDICAL CONDITIONS FIRST. If its not an underlying medical condition, then proceed with psychiatric diagnosing. In working with many social workers, psychologists, and psychiatrists, I rarely see them looking towards medical conditions when a client comes in with mood or anxiety issues.

Being diagnosed with Celiac has been a fantastic life lesson for me, especially when it comes to my work with clients. In fact, a coworker of mine called me last week to get some advice about a 17 year old female in one of our residential programs who is displaying significant anxiety and is starting to refuse certain meals. My first response? "Have you tested her for food intolerances?" There was a long pause followed by "Huh?" from my coworker. I explained that it might not just be for "attention" but maybe this young lady has some food intolerances which is making her feel sick and causing her to avoid certain foods. After we rule this stuff out, then we can look at what might be behind her behaviors. And the kicker was the response, "So does this mean that I should get nursing staff involved??" "YES!!!!"

Whether the Celiac or the anxiety came first, both are very real, and very frustrating. Hang in there! I hope it gets better!!!

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I'm really happy for you Erin. I am a completely different person on gluten also. I attribute a lot of it to nervous system inflammation.. that "gluten head" that was mentioned. When I eat gluten i'm transported into a nearly psychotic type of world. Perception disturbances, a feeling that all visual and auditory things are going to morph at any second along with paranoia, panic attacks, motor skill problems, memory loss, random crying, sense of doom, a complete inability to relate to the energy of other people. It's like the energy of other people look more like monsters coming out of the object of a body, than a human being. I also become rather mute, i'm not sure why, it's like something that happens in my brain allows me to have dark emotions but no thoughts. So throughout childhood, I was rather mute. That changed amazingly when I cut out gluten and suddenly I talk too much at times and have opinions. I still have depression, but the world around me doesn't look dark and scary, and there is no intensity of panic attached to my depression.

I would really love if there was more research done on the effects of gluten on the brain and nervous system. also adrenal glands.

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Of all the doctors I talked to about being diagnosed for celiac, all of them said I should see a mental health professional first, before testing.

Then I got my positive blood test results back and they changed their tune.

Erin80, everything you've written is also my experience. I turned 35 a few days after diagnosis. So my youth was spent with gluten; the rest is my time.

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    No Hereditary Link in NCGS
    Researchers know for certain that genetic heredity plays a major role in celiac disease. If a first-degree relative has celiac disease, then you have a statistically higher risk of carrying genetic markers DQ2 and/or DQ8, and of developing celiac disease yourself. NCGS is not known to be hereditary. Some research has shown certain genetic associations, such as some NCGS patients, but there is no proof that NCGS is hereditary. No Connection with Celiac-related Disorders
    Unlike celiac disease, NCGS is so far not associated with malabsorption, nutritional deficiencies, or a higher risk of autoimmune disorders or intestinal malignancies. No Immunological or Serological Markers
    People with celiac disease nearly always test positive for antibodies to gluten proteins. Researchers have, as yet, identified no such antobodies or serologic markers for NCGS. That means that, unlike with celiac disease, there are no telltale screening tests that can point to NCGS. Absence of Celiac Disease or Wheat Allergy
    Doctors diagnose NCGS only by excluding both celiac disease, an IgE-mediated allergy to wheat, and by the noting ongoing adverse symptoms associated with gluten consumption. WHAT ABOUT IRRITABLE BOWEL SYNDROME (IBS) AND IRRITABLE BOWEL DISEASE (IBD)?
    IBS and IBD are usually diagnosed in part by ruling out celiac disease. Many patients with irritable bowel syndrome are sensitive to gluten. Many experience celiac disease-like symptoms in reaction to wheat. However, patients with IBS generally show no gut damage, and do not test positive for antibodies to gliadin and other proteins as do people with celiac disease. Some IBS patients also suffer from NCGS.

    To add more confusion, many cases of IBS are, in fact, celiac disease in disguise.

    That said, people with IBS generally react to more than just wheat. People with NCGS generally react to wheat and not to other things, but that’s not always the case. Doctors generally try to rule out celiac disease before making a diagnosis of IBS or NCGS. 
    Crohn’s Disease and celiac disease share many common symptoms, though causes are different.  In Crohn’s disease, the immune system can cause disruption anywhere along the gastrointestinal tract, and a diagnosis of Crohn’s disease typically requires more diagnostic testing than does a celiac diagnosis.  
    Crohn’s treatment consists of changes to diet and possible surgery.  Up to 10% of Crohn's patients can have both of conditions, which suggests a genetic connection, and researchers continue to examine that connection.
    Is There a Connection Between Celiac Disease, Non-Celiac Gluten Sensitivity and Irritable Bowel Syndrome? Large Number of Irritable Bowel Syndrome Patients Sensitive To Gluten Some IBD Patients also Suffer from Non-Celiac Gluten Sensitivity Many Cases of IBS and Fibromyalgia Actually Celiac Disease in Disguise CELIAC DISEASE DIAGNOSIS
    Diagnosis of celiac disease can be difficult. 

    Perhaps because celiac disease presents clinically in such a variety of ways, proper diagnosis often takes years. A positive serological test for antibodies against tissue transglutaminase is considered a very strong diagnostic indicator, and a duodenal biopsy revealing villous atrophy is still considered by many to be the diagnostic gold standard. 
    But this idea is being questioned; some think the biopsy is unnecessary in the face of clear serological tests and obvious symptoms. Also, researchers are developing accurate and reliable ways to test for celiac disease even when patients are already avoiding wheat. In the past, patients needed to be consuming wheat to get an accurate test result. 
    Celiac disease can have numerous vague, or confusing symptoms that can make diagnosis difficult.  Celiac disease is commonly misdiagnosed by doctors. Read a Personal Story About Celiac Disease Diagnosis from the Founder of Celiac.com Currently, testing and biopsy still form the cornerstone of celiac diagnosis.
    TESTING
    There are several serologic (blood) tests available that screen for celiac disease antibodies, but the most commonly used is called a tTG-IgA test. If blood test results suggest celiac disease, your physician will recommend a biopsy of your small intestine to confirm the diagnosis.
    Testing is fairly simple and involves screening the patients blood for antigliadin (AGA) and endomysium antibodies (EmA), and/or doing a biopsy on the areas of the intestines mentioned above, which is still the standard for a formal diagnosis. Also, it is now possible to test people for celiac disease without making them concume wheat products.

    BIOPSY
    Until recently, biopsy confirmation of a positive gluten antibody test was the gold standard for celiac diagnosis. It still is, but things are changing fairly quickly. Children can now be accurately diagnosed for celiac disease without biopsy. Diagnosis based on level of TGA-IgA 10-fold or more the ULN, a positive result from the EMA tests in a second blood sample, and the presence of at least 1 symptom could avoid risks and costs of endoscopy for more than half the children with celiac disease worldwide.

    WHY A GLUTEN-FREE DIET?
    Currently the only effective, medically approved treatment for celiac disease is a strict gluten-free diet. Following a gluten-free diet relieves symptoms, promotes gut healing, and prevents nearly all celiac-related complications. 
    A gluten-free diet means avoiding all products that contain wheat, rye and barley, or any of their derivatives. This is a difficult task as there are many hidden sources of gluten found in the ingredients of many processed foods. Still, with effort, most people with celiac disease manage to make the transition. The vast majority of celiac disease patients who follow a gluten-free diet see symptom relief and experience gut healing within two years.
    For these reasons, a gluten-free diet remains the only effective, medically proven treatment for celiac disease.
    WHAT ABOUT ENZYMES, VACCINES, ETC.?
    There is currently no enzyme or vaccine that can replace a gluten-free diet for people with celiac disease.
    There are enzyme supplements currently available, such as AN-PEP, Latiglutetenase, GluteGuard, and KumaMax, which may help to mitigate accidental gluten ingestion by celiacs. KumaMax, has been shown to survive the stomach, and to break down gluten in the small intestine. Latiglutenase, formerly known as ALV003, is an enzyme therapy designed to be taken with meals. GluteGuard has been shown to significantly protect celiac patients from the serious symptoms they would normally experience after gluten ingestion. There are other enzymes, including those based on papaya enzymes.

    Additionally, there are many celiac disease drugs, enzymes, and therapies in various stages of development by pharmaceutical companies, including at least one vaccine that has received financial backing. At some point in the not too distant future there will likely be new treatments available for those who seek an alternative to a lifelong gluten-free diet. 

    For now though, there are no products on the market that can take the place of a gluten-free diet. Any enzyme or other treatment for celiac disease is intended to be used in conjunction with a gluten-free diet, not as a replacement.

    ASSOCIATED DISEASES
    The most common disorders associated with celiac disease are thyroid disease and Type 1 Diabetes, however, celiac disease is associated with many other conditions, including but not limited to the following autoimmune conditions:
    Type 1 Diabetes Mellitus: 2.4-16.4% Multiple Sclerosis (MS): 11% Hashimoto’s thyroiditis: 4-6% Autoimmune hepatitis: 6-15% Addison disease: 6% Arthritis: 1.5-7.5% Sjögren’s syndrome: 2-15% Idiopathic dilated cardiomyopathy: 5.7% IgA Nephropathy (Berger’s Disease): 3.6% Other celiac co-morditities include:
    Crohn’s Disease; Inflammatory Bowel Disease Chronic Pancreatitis Down Syndrome Irritable Bowel Syndrome (IBS) Lupus Multiple Sclerosis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Psoriasis Rheumatoid Arthritis Scleroderma Turner Syndrome Ulcerative Colitis; Inflammatory Bowel Disease Williams Syndrome Cancers:
    Non-Hodgkin lymphoma (intestinal and extra-intestinal, T- and B-cell types) Small intestinal adenocarcinoma Esophageal carcinoma Papillary thyroid cancer Melanoma CELIAC DISEASE REFERENCES:
    Celiac Disease Center, Columbia University
    Gluten Intolerance Group
    National Institutes of Health
    U.S. National Library of Medicine
    Mayo Clinic
    University of Chicago Celiac Disease Center