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  1. Betty Wedman-St Louis, PhD, RD

    "Vaccine" for Celiac Disease

    An experimental "vaccine" called Nexvax 2 is being scheduled for human clinical trials to evaluate its effectiveness in celiac disease. Immusan T is a biotechnology company focusing on developing therapeutic vaccines and received $40 million in 2017 to fund Nexvax 2 to reduce the "suffering of those with celiac disease since it is a serious inflammatory autoimmune disease caused from gluten". Since there is no cure for celiac disease except following a strict gluten-free diet, symptoms can vary greatly based on age and diet content. Children with DQ2 and DQ8 genes may have a swollen belly, chronic diarrhea and poor appetite which can cause delayed growth. Adults often experience abdominal pain, fatigue, anemia and joint pain. When grain products- containing gluten and gliadin- are consumed tissue transglutaminase in the small intestinal lining signals an immune response that produces antibodies which attack the lining of the small intestine. This leads to malabsorption of nutrients from food. Nutrient deficiencies cause liver, bone and neuron damage resulting in abnormal growth, poor tissue repair and numerous symptoms. Allergy vs Auto-Immune Disease It is important to understand that celiac disease and dermatitis herpetiformis (itchy, blistery skin rash) are auto-immune disorders NOT an allergy to gluten. Allergies occur when the immune system overreacts to a compound causing the release of histamines. An auto-immune disorder results when the body misidentifies a substance as dangerous and causes the immune system to attack the body's own tissue. Celiac Disease Epidemic Celiac disease and gluten enteropathies are a growing epidemic in the U.S. and across the world due to the increasing use of processed foods and food additives that use grain products for thickening, stability and dietary supplement fillers. Environmental factors may contribute to a person becoming gluten intolerant even after decades of consuming gluten without suffering serious health consequences. How "Vaccine" Works The "vaccine" Nexvax 2 is designed to work similar to allergy shots according to Live Science (Nov. 9, 2018). The treatment involves twice weekly injections administered over a 16 week (4 months) period to reprogram T cells to begin to tolerate gluten and suppress immune destruction of the villi in the small intestine. No available data is currently available on the ingredients used in Nexvax 2 so safety can not be assessed at this point. What is known is that vaccines DO NOT mean immunization whether through injection or oral dosing. Immunization is a process for developing tolerance and protection against infections. Dorland's Medical Dictionary states vaccination means to "inject a suspension of attenuated or killed microorganisms administered for prevention or treatment of infectious disease". The Center for Disease and Prevention Control (CDC) states that vaccination does NOT guarantee immunity. Natural immunity comes only after a person recovers from the actual disease, and not all who receive a vaccination will have immunity. No vaccine is 100% effective because everyone's immune system reacts differently. Before lining up to participate in the clinical trials, adapt a more educated approach to vaccination safety regarding a disease managed very effectively by a healthy gluten-free, lectin-free diet. It is a personal decision for adults with celiac disease whether or not they chose to vaccinate. It will be many years before the safety of this celiac disease "vaccine" can be established. On a personal note: I have been a celiac for more than 70 years and would never consider a "vaccine" just so I didn't have to worry about hidden gluten.
  2. Celiac.com 04/24/2014 - Though some celiacs will tell you they’re content to remain gluten-free for life, being able to freely consume gluten is the dream of many a person with celiac disease. ImmusanT is one of the few companies working on an actual vaccine for celiac disease. Over the next few months, ImmusanT is likely to begin reporting data from two separate early-stage clinical trials for NexVax2, a celiac disease vaccine. That data will offer the first glimpse into the potential for ImmusanT to treat celiac disease, and into the viability of the company’s peptide immunotherapy platform. The current two studies are Phase 1b trials, designed to confirm the safety of NexVax2, and to find a range of potential doses for the company’s next trials. Success at this stage still means a very long process for ImmusanT, as numerous clinical hurdles remain. Meanwhile, several other companies trying to find non-vaccine treatments for celiac disease. Both San Carlos, CA-based Alvine Pharmaceuticals and Baltimore, MD-based Alba Therapeutics, for instance, are developing drugs to supplement an existing gluten-free diet. Rather than being full-blown vaccines, these drugs are intended to reduce or eliminate adverse gluten-reactions due to simple gluten-contamination. Another company, Sitari Pharmaceuticals, fueled by $10 million in capital, and a joint venture with GlaxoSmithKline and Avalon Ventures, is also looking to pursue treatments for the digestive disorder. For its part, ImmusanT remains committed to its goal of developing a vaccine that will allow celiac patients to eat all the gluten they want. The company says its drug is currently the only treatment in development “focusing on disease modification so patients can resume an unrestricted diet.” Source: Xconomyc.com
  3. Celiac.com 01/17/2019 - Kids with celiac disease, especially those who are recently diagnosed, are not getting proper follow-up care, according to the latest report. A team of researchers recently set out to assess the follow-up care of children with biopsy-confirmed celiac disease over a minimum of three years following diagnosis. Their results appear in Clinical Gastroenterology and Hepatology. The research team included Bradley A. Blansky MS, Zackary J. Hintze BA, Eaman Alhassan MD, Alan M. Leichtner MD MCHPE, Dascha C.Weir MD, and Jocelyn A. Silvester MD, PhD. They are variously affiliated with the Harvard Celiac Disease Program, Boston, MA; the Boston Children’s Hospital, Harvard Medical School, Boston, MA; Boston University, Boston, MA; the Department of Medicine, West Virginia University, Morgantown, WV; the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; the Rady College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB. For their study, the research team used a database to randomly select children with biopsy-confirmed celiac disease at Boston Children's Hospital from January 1, 2010 to December 31, 2014. The team followed about 50 cases per year. The researchers reviewed patient medical records for a minimum of 3 years of observation following diagnosis. Any child not receiving a gastrointestinal (GI) visit for 18 months was marked lost to follow-up. The 241 eligible subjects averaged about 10 years old at diagnosis, and 63% were female. Nearly all of the children reported symptoms, with 24% complaining of abdominal pain, and 14% of experiencing constipation. Just 2% of the children showed no symptoms at all. On the upside, more than 80% of the children saw a dietitian, with just under one-in-three kids attending both a dietitian-led class and an individual consultation. But the records show that 25% of the kids were lost to follow-up within a year of diagnosis, and that nearly 10% received no GI visits at all after their diagnostic biopsy. Read more at: Clinical Gastroenterology and Hepatology (PAYWALL)
  4. Celiac.com 03/17/2014 - Researchers know a great deal about the function of human digestive proteases in gluten proteins, but they know very little about the role of intestinal microbes in metabolizing those proteins. A team of researchers recently set out to examine the isolation and characterization of human gut bacteria involved in the metabolizing gluten proteins. The researchers include Alberto Caminero, Alexandra R. Herrán, Esther Nistal, Jenifer Pérez-Andrés, Luis Vaquero, Santiago Vivas, José María G. Ruiz de Morales, Silvia M. Albillos, and Javier Casqueiro. They are variously affiliated with the Instituto de Biología Molecular, Genómica y Proteómica (INBIOMIC), and the Instituto de Biomedicina (IBIOMED) at the Campus de Vegazana of the Universidad de León, with the Área de Microbiología, Facultad de Biología y Ciencias Ambientales at the Universidad de León, with the Departamento de Inmunología y Gastroenterología, Hospital de León, León, Spain, and with the Instituto de Biotecnología (INBIOTEC) de León, all in León, Spain. For their study, the team cultured 22 human fecal samples, with gluten as the principal nitrogen source, and isolated 144 strains belonging to 35 bacterial species that may play a role in gluten metabolism in the human gut. They found that 94 of the isolated strains were able to metabolize gluten, 61 strains showed an extracellular proteolytic activity against gluten proteins, while several strains showed a peptidasic activity toward the 33-mer peptide, which is an known peptide trigger in celiac disease patients. Most of the isolated strains belong to the phyla Firmicutes and Actinobacteria, mainly from the genera Lactobacillus, Streptococcus, Staphylococcus, Clostridium and Bifidobacterium. They found that the human gut hosts a wide variety of bacteria capable of using gluten proteins and peptides as nutrients. These bacteria could play an important role in gluten metabolism and could offer promising new treatment possibilities for celiac disease. Source: Onlinelibrary.wiley.com. DOI: 10.1111/1574-6941.12295
  5. Celiac.com 01/14/2019 - There are a number of new drugs in development that are designed to treat celiac disease. In addition to a possible vaccine, those drugs include enzymes and other drugs that are designed to reduce or eliminate the body’s adverse reaction to gluten through various mechanisms. Here's a 2019 status update for every drug for treating celiac disease currently in development: ALV003—Created by Alvine Pharmaceuticals, is a combination of two enzymes that break down gluten before it can provoke an immune reaction. The drug is a powder to be dissolved in water and taken before meals. ALV003 passed a phase 2 clinical trial, and results were published in the June 2014 issue of Gastroenterology. Post-trial biopsies showed that ALV003 prevented intestinal damage in 34 volunteers with celiac disease, each of whom ate 2 grams of gluten per day for six weeks, in addition to taking ALV-003. Phase 2b, a 12-week trial, is now underway. AN-PEP (aspergillus niger prolyl endopeptidase)—Created by DSM Food Specialties, AN-PEP is another enzyme that degrades gluten. AN-PEP is believed to work best when taken while gluten is still in the stomach. A 2013 study showed AN-PEP to be safe, but failed to show that the enzyme had any effect, so further study is under way. That study appeared in the World Journal of Gastroenterology. In a 2018 study, AN-PEP extensively degraded gluten concentrations of up to 80,000 mg/kg in rye flour, rye sourdough, and sourdough starter under specific temperatures and pH values, while leaving the microorganisms in the sourdough starter fully intact. ActoBiotics—Created by ActoGenX uses Lactococcus lactis as an expression system to locally secrete bio-therapeutics such as cytokines, antibodies, hormones, etc. Early pre-clinical work with a genetically altered L. lactis secreting a peptide derived from gliadin demonstrated an in vivo suppression of gluten sensitization. Specifically, Huigbregtse et al. engineered L. lactis to secrete a deamidated DQ8 gliadin epitope (LL-eDQ8d) and studied the induction of Ag-specific tolerance in NOD ABo DQ8 transgenic mice [34]. Although apparently not part of the ActoGenX development program, recent work by Galipeau et al. also deserves mention in this context. The group treated gluten-sensitive mice with elafin, a serine protease inhibitor, delivered by the L. lactis vector, and found normalization of inflammation, improved permeability, and maintained ZO-1 expression. There is speculation that this is due to reduced deamidation of gliadin peptide. AVX176—Created by Avaxia Biologics, is an investigational oral antibody drug patented to provide "Antibody Therapy for Treatment of Diseases Associated with Gluten Intolerance." The patent, which expires on May 27 2029. AVX176 provides broad coverage for treating celiac disease using orally administered antibodies produced by Avaxia's proprietary platform technology. BL-7010—by BioLineRx, is a novel co-polymer for the treatment of celiac disease, which significantly reduces the immune response triggered by gluten. This drug has been shown in mice to reduce the immune system response that leads to intestinal damage and villous atrophy in celiac disease. BL-7010 actually binds to the gluten protein, reducing the protein's toxicity.The drug, with the gluten molecule attached, then passes harmlessly through the digestive system to be expelled as stool. BL-7010 has undergone safety testing in humans and was found to be well tolerated. According to BioLineRx, testing will begin in mid-2015 to see if the drug works as expected to diminish gluten's effects on the body. However, BL-7010 is designed to protect only against gluten cross-contamination; it won't allow people with celiac disease to eat large amounts of gluten. CCR9—by Chemocentryx, is a drug called vercirnon, which is also known as Traficet-EN, or CCX282B), and was originally intended for patients with moderate-to-severe Crohn's disease. CCR9 has completed one Phase 2 trial in 67 patients with celiac disease. However, despite the completion of the trial several years ago, no results relating to celiac disease have been made public or published. Egg Yolk Enzyme—Little is known about efforts to develop a celiac treatment that uses egg yolk to coat gluten and allow it to pass through the body undetected, thus preventing an adverse gluten reaction in sensitive individuals. Like most other drugs being developed, this treatment would work to prevent reactions to small amounts of gluten, rather than as a cure for celiac disease. Recent news shows that the egg yolk enzyme is safe for humans. GliadinX (Aspergillus niger)—GliadinX is a dietary supplement with the highest concentration of AN-PEP, Prolyl Endopeptidase (Aspergillus Niger), the most effective enzyme proven to break down gluten in the stomach. This high potency enzyme formulation is specifically designed to break down gliadin. GliadinX does not prevent or cure celiac disease. However, clinical research has shown that it effectively breaks down gliadin into small, harmless fragments before it can reach the small intestine. INN-202 (Larazotide Acetate)—Created by Alba Therapeutics and later acquired by Innovate Pharmaceutical, and renamed INN-202, larazotide acetate works by blocking a protein that carries pieces of gluten across the gut. Results of a phase 2 trial of larazotide acetate appear in the February 2015 edition of Gastroenterology. While INN-202 may greatly reduce the symptoms of gluten exposure in celiacs, it is unlikely that a permit consumption of unlimited amounts of gluten. The U.S. Food and Drug Administration (FDA) has fast-tracked the drug. Phase III clinical trials are currently underway. Results of the trial should be available soon. Nexvax2—Created by ImmusanT, Nexvax2 is touted as a vaccine, but works much like an allergy shot. Nexvax2 combines three proprietary peptides that elicit an immune response in celiac disease patients who carry the immune recognition gene HLA-DQ2. Similar to allergy shots, the vaccine is designed to reprogram gluten-specific T cells triggered by the patient's immune response to the protein. Nexvax2 exposes the immune system to gluten in a controlled way so that immune cells that are usually activated get turned off or eliminated. So far, Nexvax2 has completed a phase 1 trial showing it to be safe, and the company has begun Phase II trials on humans in Australia and New Zealand. Saliva Rothia—Researchers at the Henry M. Golden School of Dental Medicine were looking at how proteins in general break down in saliva when they discovered an enzyme in a bacterium called Rothia that pulverized gluten as if it were Pac Man. That happy accident has led to a new stream of study that has moved beyond petri dishes to study the effect of the so-called ‘subtilisin,’ or protein-ingesting enzyme on the tiny digestive systems of mice. In so doing, they have found another bacterium, B. subtilis, which produces an enzyme similar to the Rothia one and is already safely consumed in Japan in a fermented soybean dish called ‘natto.’ A 2018 Boston University report concludes that “oral Rothia bacteria to gliadin digestion and pharmaceutical modification can protect Sub-A from auto-digestion as well as from acidic insults, thus rendering the usefulness of coated subtilisins as a digestive aid for gluten degradation.” ZED1227—Created by Dr. Falk Pharma and Zedira recently announced the start of phase II clinical trials for the drug candidate ZED1227, a direct acting inhibitor of tissue transglutaminase. ZED1227 molecules work by targeting the dysregulated transglutaminase within the small intestine in order to suppress the immune response to gluten which drives the disease process. Sources: An Update on Every Celiac Disease Drug Currently in Development Inside The Race for a Celiac Disease Treatment Promising Celiac Disease Drugs in the Pipeline Development of drugs for celiac disease: review of endpoints for Phase 2 and 3 trials
  6. Celiac.com 12/06/2018 - The growing popularity of gluten-free foods has led to numerous new products for consumers, but it has also led to some problems. One recent study showed that up to one-third of foods sold as gluten-free contain gluten above 20ppm allowed by federal law. Other studies have shown that restaurant food labeled as “gluten-free” is often contaminated with gluten. The problem of gluten in commercial food labeled gluten-free is not isolated to the United States. Recent studies abroad show that the problem exists in nearly every gluten-free market in every country. In Australia, for example, researchers from the Walter and Eliza Hall Institute in Melbourne found detectable gluten in almost 3% of 256 commonly purchased “gluten-free” manufactured foods, a study published in the Medical Journal of Australia on Monday says. Furthermore, the study shows that nearly 10% of restaurant dishes sold as "gluten-free" contain unacceptable levels of gluten. Now, the Australians have a stricter standard than nearly anyone else, so look for them to be on top of potential problems with gluten contamination in gluten-free products. The study did not name the food manufacturers responsible for the contaminated products, but did note that better, more frequent gluten testing by manufacturers would make gluten-free foods safer for people with celiac disease. In a related study, the same researchers found in May that nearly one in ten samples of “gluten-free” dishes from restaurants within the City of Melbourne contained gluten levels in excess of the official Food Standards Australia New Zealand definition of gluten-free. “It’s troubling to think that these foods could be hindering the careful efforts of patients trying their best to avoid gluten,” an author of the study, Dr Jason Tye-Din, said. A spokeswoman from Coeliac Australia said the organization was taking the findings seriously. “The research team that conducted this study has liaised with the food companies and is following up the positive samples with further retesting to ensure the issue is resolved,” she said. In addition to urging consumers to be diligent in reading labels, and to report any suspect products, “Coeliac Australia advises all people with coeliac disease to have regular medical check-ups as they do have a serious autoimmune condition and medical assessment is important to determine that their gluten-free diet is going well and no complications are developing.” Read more at: TheGuardian.com
  7. Celiac.com 01/09/2019 - People with celiac disease who eat a gluten-free diet generally see an improvement in gut health over the next months and years. That’s true, but many people with celiac disease who eat a gluten-free diet still have gut damage many months later. What exactly is the connection between gut health and a gluten-free diet in people with celiac disease? To try to answer that question, a team of researchers recently set out to analyze the relationships between pre-diagnosis celiac serology, duodenal histopathology, primary presenting symptoms, celiac-related comorbidity and response to treatment in a modern cohort with new diagnosis of celiac disease. The research team included Oliver Cronin, Emma Flanagan, and Damian Dowling. They are variously affiliated with the Department of Gastroenterology, University Hospital Geelong, in Geelong, Australia, and the Department of Gastroenterology at St Vincent’s Hospital in Fitzroy, Australia. The team’s retrospective cohort study included 99 participants diagnosed with celiac disease between 1999 and 2013. For each patient, the team recorded baseline characteristics, celiac serology, and small bowel histopathology. Several patients underwent a repeat small bowel biopsy. The team used logistic regression to determine independent associations. Patients ranged from 30 to 53 years old, and averaged 43 years at diagnosis. Women made up nearly seventy percent of the group. The researchers used standard Marsh-Oberhuber Score (MS) to rate damage to intestinal villi. At diagnosis, nearly half of the patients showed total villous blunting (MS 3c), while twelve patients showed subtotal villous blunting (MS 3b), and 29 patients showed partial villous blunting (MS 3a). The extent of villous blunting was independent of symptom prevalence prior to diagnosis. A total of 87 patients received repeat small bowel biopsy at an average of 7 months after their initial biopsy. Meanwhile, a total of 34 patients had biopsy results at or above MS 3a, compared to 90 patients at the initial biopsy. 24 of the 34 patients reported following a strict a gluten free diet (GFD). Persistent MS at or above grade 3a at repeat biopsy was not associated with symptoms (P = 0.358) or persistent positive celiac serology. This study shows that the severity of the small bowel mucosal lesion at celiac disease diagnosis is independent of both symptoms and serology, and that neither are good predictors of mucosal health. While numerous patients do see histological improvement on a gluten-free diet, many newly diagnosed celiac patients show ongoing mucosal damage after many months on a gluten-free diet. An absence of celiac disease antibodies did not preclude ongoing mucosal damage. Basically, not all celiac patients see rapid gut healing, even on a strict gluten-free diet. Also, people with celiac disease can still have mucosal damage, even if they test negative for celiac disease antibodies. Source: World J Gastrointest Pharmacol Therv.9(6); 2018
  8. Celiac.com 12/31/2018 - Rates of celiac disease are about triple for patients who also suffer from cystic fibrosis, compared to those without cystic fibrosis. A team of researchers recently investigated the molecular similarities between celiac disease and cystic fibrosis. Specifically, they set out to examine the role of mutations of the gene coding for cystic fibrosis transmembrane conductance regulator (CFTR), an anion channel pivotal for epithelial adaptation to cell‐autonomous or environmental stress. The study was led by Luigi Maiuri, Valeria Raia, and Guido Kroemer. They are variously affiliated with the San Raffaele Scientific Institute in Milan, Italy, the University of Naples Federico II in Italy, and the Paris Descartes University in France. Their research shows a connection between celiac disease and cystic fibrosis, and suggests that a compound developed for cystic fibrosis may also treat celiac disease. The results might bring us closer to a treatment for celiac disease. Failure of the cystic fibrosis transmembrane conductance regulator in cystic fibrosis patients triggers the accumulation of mucus in the patients’ lungs and intestine. By activating the immune system, the mechanism underlying CFTR malfunction causes several reactions in the lungs and other organs. These reactions are very similar to immune responses to gluten in celiac patients. Intrigued, Maiuri, Kroemer, and their colleagues took a closer look at the molecular underpinnings of these similarities. For people with celiac disease, eating gluten triggers the immune system to attack the mucus inside the small intestine. This immune attack presents as classic celiac symptoms, such as bloating, nausea, vomiting, diarrhea, and upset stomach. The team's findings appear in The EMBO Journal, and point to possible new therapies and treatments for celiac disease. The most promising part of the team's data indicate that CFTR potentiators, used to treat cystic fibrosis, may also be effective in treating celiac disease. With researchers revealing new connections between celiac and numerous other diseases, it's a very exciting time for celiac research. As researchers learn more about the connection between celiac disease and cystic fibrosis, look for new treatments for celiac disease in the not too distant future. Read more at: Medicalnewstoday.com
  9. Celiac.com 01/07/2019 - Researchers have made progress in spotting celiac disease without biopsy in children with certain parameters. Can the same be done for adults? A team of researchers recently set out to evaluate the accuracy of serology-based criteria in adults with variable pre-test probabilities for celiac disease. The research team included V Fuchs, K Kurppa, H Huhtala, K Laurila, M Mäki, P Collin, T Salmi, L Luostarinen, P Saavalainen, and K Kaukinen. New criteria for diagnosing celiac disease in children allow doctors to forgo duodenal biopsies in children who have symptoms, positive blood tests, and celiac disease-associated genes. There’s currently no good data on whether such an approach might work for adults with certain clinical presentations of celiac disease. Three study cohorts included 421 adults with high-risk clinical celiac disease suspicion, 2,357 moderate-risk family members of celiac patients, and 2,722 low-risk individuals from the general population. The team collected blood tests and other physical patient data. Their "triple criteria" for celiac disease included transglutaminase 2 antibodies more than ten times the upper limit of normal, positive endomysium antibodies, and appropriate genetics, but required no symptoms. The diagnosis was made by grading the intestinal biopsies. In all, 274 patients were diagnosed with celiac disease. Of these, 59 high-risk subjects, 17 moderate-risk subjects, and 14 low-risk subjects fulfilled the "triple criteria.” All had histologically proven celiac disease, giving the criteria a positive predictive value of 100%. Altogether, 90 of the 274 newly diagnosed patients could have avoided biopsy. That’s one in three patients who could have avoided biopsy. In all, 37% of high-risk, 20% of moderate-risk, and 48% of low-risk patients could have avoided biopsy. Biopsies of "triple positive" subjects showed no histological findings other than celiac disease. The results of this study are exciting, because it shows that the “triple criteria” can be used by doctors to reliably diagnose celiac disease in adults without using biopsy. Implementing these diagnostic criteria would make diagnosing celiac disease easier in many cases, and will reduce the number of endoscopies by one-third. That’s a winning result all the way around. Source: Aliment Pharmacol Ther. 2018 Dec 27. doi: 10.1111/apt.15109. The researchers in this article are variously affiliated with the Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; the Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland; the Tampere Faculty of Social Sciences, University of Tampere, Tampere, Finland; the Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; the Department of Dermatology, Tampere University Hospital, Tampere, Finland; the Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland; the Research Programs Unit, Immunobiology, and Haartman Institute, Department of Medical Genetics, University of Helsinki, Helsinki, Finland; the Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
  10. Celiac.com 01/03/2019 - Celiac disease is common in Saudi Arabia, affecting about 1.5% of the country's total population, according to a recent mass screening study. A team of researchers recently set out to determine the frequency of celiac disease-predisposing human leukocyte antigen (HLA)-DQ genotypes in the Saudi population. The research team included A Al-Hussaini, H Alharthi, A Osman, N Eltayeb-Elsheikh, and A Chentoufi. They are variously affiliated with the Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City; College of Medicine, Alfaisal University; Prince Abdullah bin Khalid Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia; the Department of Pathology and Laboratory Medicine, Division of Immunology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia; the Department of Immunology, University of Mohammed VI for health sciences, Casablanca, Morocco. For their cross-sectional population-based study, the team enrolled 192 randomly selected healthy school children, who all tested negative for tissue transglutaminase-IgA. The team then used polymerase chain reaction sequence-specific oligonucleotide probes to type the children for D QA1 and D QB1 genes. More than half of the children carried the high-risk celiac disease-associated HLA-DQ molecules at the following rates: homozygous DQ2.5 ( 2.6%), DQ2.5/DQ2.2 ( 4.7%), heterozygous DQ2.5 ( 28.15%), homozygous DQ8 ( 4.2%), DQ8/DQ2.2 ( 3.6%), and double dose DQ2.2 ( 9.4%). Another 13% had low-risk celiac disease-associated HLA-DQ molecules, single dose DQ2.2 and heterozygous DQ8. In the ultra low-risk groups, subjects without alleles that promote DQ2/DQ8 variants (33.5%), 13.5% carried only one of the alleles of the high-risk HLA-DQ2.5 heterodimer called "half-heterodimer" (HLA-DQA1*05 in 12% and HLA-DQB1* 02 in 1.5%), and 20.8% lacked all the susceptible alleles (DQX.x). The celiac disease-risk groups showed no important differences in gender distribution. More than half the healthy general Saudi population carries celiac disease-predisposing HLA-DQ genotypes, one of the highest general rates in the world; a fact that may help to explain the high rates of celiac disease in the Saudi population. Source: Saudi J Gastroenterol. 2018 Sep-Oct;24(5):268-273. doi: 10.4103/sjg.SJG_551_17
  11. Yvonne (Vonnie) Mostat

    Out, Damned Spot!

    Celiac.com 12/22/2018 - “Out I say. One, two, why then `tis time to do`t - Hell is murky!” Never considered myself Lady Macbeth, but I have had blood on my hands and sometimes screamed, ``Out all you damned itchy spots` in pure frustration. My story of being a celiac with dermatitis herpetiformis is one that nightmares are made of. Sit tight and you will see what I mean! My medical journey has been full of misadventures. My brother has often jokingly said, “M.D. does not stand for “Medical Divinity” and he is so right. I was misdiagnosed in my twenties as having irritable bowel disease after a busy specialist undertook to do a colonoscopy for me in between his regular patients and during my lunch hour working as a nurse. I took his word for it and rid myself of irritating foods like steaks and corn and cruciferous vegetables. I was preparing barbecues for my family, eliminating the meat and eating the hamburger bun. I was a busy nurse and active jogger. I loved hiking and canoeing. The medication I was given for my so called ‘irritable bowel’ was not working. One physician told me that when a physician does not know what is wrong with a patient’s gastro-intestinal bowel problems the all encompassing term ‘irritable bowel’ is often used. If the patient comes back again and again the label ‘depression’ is tacked onto her chart. Not all physicians are as blasé as the ones I have had to deal with, but I do warn you to be careful and check everything. I am writing this from the other side, and I have seen so many things that would ‘knock your socks off!’ Throughout my thirties I jogged early in the morning before my shift; often jogging off into the bushes, Kleenex in hand, hoping and praying no-one was around to see me taking a bathroom break. Those of you suffering from loose bowels because of ingesting gluten know only too well what I am talking about! We went out to our favourite Chinese Restaurant, time and time again only to make a “pit stop” at the nearby soccer pitch so I could retch up our dollars on the turf. I still received the same diagnosis, the same medication. Normally I weighed 100 pounds in those days and on a five foot one and a half frame my weight was not bad. (Heavy on the ½ inch!) Slowly my weight declined. Stress I was told - yet another diagnosis. Slowly I was limiting my foods to yogurts and sandwiches. Throughout my forties my problems exacerbated until the November before my daughter’s wedding. Like an explosion I had spots all over the back of my head, upper arms and thighs. Oh I itched, but when I scratched the tops off the sores they stung and hurt. It was hard to work as a nurse scratching your head. I am surprised that someone did not whisper a word to a doctor to have me checked for fleas. Fleas I thought and bought a bottle of Kwellada and dosed not only myself but my husband with it! The bedding was almost boiled, our nails soaked in Pinesol. All was to no avail. I was referred to an allergist whose nurse dealt with me more than he did. He rushed into the room, did not check my sores at all but suggested bed bugs. Agghh! Being a neat freak everything had to go except my husband! The November prior to my daughter’s wedding, and near the end of my forties, I was an itching bleeding mess. Of course I had a sandwich every day for lunch and found that I itched far more in the afternoon. My white nurse’s stockings were covered in blood at the back and on the way home from work my therapy was scraping a comb through my scalp and tearing all the spots apart. Immediately I arrived home my husband knew I would rush upstairs and grab a cool shower for the second time that day. The last Saturday in November after itching my way through trying on wedding dresses; can you imagine? Beautiful shop and conceited sales clerks looking askance at my legs. I had reached the end of my itching rope. The other physician in the two physician practice I attended was on Saturday call and I walked in. He examined my spots, actually looked at my scalp, asked me some very relevant questions about my condition, exited the examining room and came back with his Dorland’s Medical Dictionary, the guidebook for all doctors. Dermatitis herpetiformis, he shouted. “I am almost convinced of it.” He prescribed two to four Atarax for the itch, and four Prednisone - along with the specific instruction that I follow up with my family physician, his partner, on the following Tuesday. To be sure I was in that office immediately after work on Tuesday, scratching my head and rubbing my legs together as if to start a fire right there in his office! I indicated that I had seen his partner on Saturday, spouting my instructions. “Stress” he said. He didn’t seem to have even read the notes written by his partner. I was prescribed Loxapine, four Atarax, six Prednisone, and instructions to follow-up in one week. This is where I should tell you about Loxapine. It is a drug, often given to sedate the elderly in nursing homes. Very few hospitals prescribe it anymore because of its dangerous side effects. Most medical manuals will warn against prescribing it to peri-menopausal women of low weight, and a lot even warn against giving it to women at all. It also indicates not to prescribe it for longer than three months and to monitor it closely for signs of tardive dyskinesia. (I probably now know as much about this horrible side effect as any medical physician). One thing that the Medico-Legal Handbook of the Canadian Physicians states is that when prescribing a drug not designed for the condition it is being used to treat, the physician must list all the possible side effects of that drug. I can say with all honesty that if I had known of the possible long term side effect of tardive dyskinesia I would have asked if there were any other drugs for “itchy spots” without the significant risk of not only a disfiguring condition on the outside of my body but what it could do to my internal physiology. Don’t forget, I had not yet been referred to a dermatologist who would take the time to take a biopsy of these spots! Consider that I was driving thirty-miles a day to work on this sedating drug, along with the Atarax and Prednisone. I am amazed that I did not add to this cocktail of drugs a drink or two of my own, but thankfully not being a drinking person I persisted staying awake, scratching during the night and keeping my husband awake! The wedding in January went off without a hitch. This is surprising since my daughter seemed to think I was the wedding planner extraordinaire. At our March visit my husband came in with me, both gun barrels loaded. “Why hasn’t my wife been referred to a dermatologist? Why is her mouth turning and her speech slurred, her hands trembling and her head turning?” I had “DH” without the “D”. My physician seemed to wake up.”‘Whoa, how long has she been twisting her mouth like that? She has to go off Loxapine right away. That is one of the side effects of that drug.” I saw the dermatologist the next week! He asked a barrel of questions but told me that since I was now up to ten Prednisone a day. I would have to wait two months in order to be weaned off that drug so he could biopsy the dreadful spots which seemed to have a life of their own. They marched in a line like soldiers and I was scarred where healed spots had been. My weight was now 89 pounds and my stomach muscles were as tired as I was from retching into any available toilet. After the three months were up biopsies were taken and I received a lesson about IgA deposits. I was told that in the ‘olden days’ one way of telling if a person had dermatitis herpetiformis was to put a few drops of Iodine close to an area of the lesions. Within a few days some more spots would appear, because apparently these DH spots are present under the skin and show their ugly itchy selves with Iodine. Did I try it? Of course I did! My test results were positive, silly person that I was, but thankfully the hospital laboratory results were also positive. To be thorough the dermatologist wanted me to have a bowel biopsy. Unfortunately the first gastroenterologist failed to biopsy the Jejunum part of the bowel. I had by this time searched the Internet for myself. (Oh why hadn’t I done it sooner with the Loxapine?!!) I knew about flattened villi and had started following a semi-gluten free diet. Somewhat deflated and now struggling with patients being unable to understand my speech, not being able to draw up a needle or even, when assigned to a corner to write up charts my once beautiful writing was illegible. I am surprised I was not breathalysed. Thankfully my work ethic was such that I was more to be pitied. I was referred to another gastroenterologist who did biopsy the jejunum part of the bowel and the results came back positive for celiac disease. Anyone of you who has undergone these tests knows that they are exceedingly unpleasant. Yet I was happy because I was vindicated. The dermatologist placed me on the drug Dapsone - four a day for the first week with follow-up in one week. I arrived back at his office with flowers, not in my head, in a bunch in my hands; I was ecstatic! The spots were almost gone, just some residual spots at the back of my head. I was immediately put on a gluten free diet. I was officially a celiac with dermatitis herpetiformis. The dermatologist told me that I had a severe case and it was unlikely that I would ever be able to go off Dapsone. It would be my partner for life. But I did not know how difficult the diet can be when you are a novice. He referred me to one of the top internists in B.C. who, of course, agreed with his diagnosis but also told me how to rid myself of residual stubborn “spots” at the back of my scalp. ‘Do the 5-4-3-2-1- regime with Prednisone and Dapsone and this should clear up the rest of the spots. {**You can also do this with outbreaks I was told**} Read that sentence in brackets with stars, hold the thought but ignore the instructions. Now I had another monster to deal with, far more ferocious than the DH. I was referred to the Movement Disorder Clinic at U.B.C., a Clinic I still attend to this day. I sat with Parkinson patients as well as multiple sclerosis patients and was quite terrified about my prognosis. I was assessed by the very head of the clinic who was quite angry that a “young woman” of my age was administered Loxapine for “spots” when there are so many other medications on the market one can be given for itchy spots, and before a referral to a dermatologist. It was suggested I be placed on Tetrabenazine, a drug not even approved in the United States, and a drug with a possible list of side effects that petrified me. I walked out with a compilation of literature on the drug, but without a prescription, saying I would think about it and be back in two weeks. We read every article we could get our hands on about this drug. I was not going to risk going on any neuroleptic drug. I loved my job and had to say a very tearful good-bye to it fifteen years earlier than planned. Having tardive dyskinesia I was clutzy, falling down stairs, not lifting my leg high enough to rise to the sidewalk, having my head turn to the left while sitting at a stop sign and having to wait until it returned voluntarily to full frontal position. I thank God that I had a medical insurance package in place which I had been paying into for years. I became a poster woman for medical insurance policies and instructed everyone I knew to become fully knowledgeable about any drug they were taking, to ask questions before popping any pill into their mouth. I returned in two weeks. It was not only hard for me to look in the mirror to see my facial gesticulations it drove my husband to tears watching me. Tests had shown that the drug damage had attacked me primarily on my right side, my right lung, oesophagus, and right hand more than left. Both eyebrows seemed to move up and down of their own volition though, as did my forehead. Speaking of head, my head was like one of these wooden dolls that are worked from inside. It turned to the left when it wanted to. My TMJ (temporomandibular joints) grabbed like a snapping turtle, and my dentist had a very difficult time even assessing my teeth for splints. I eventually cracked a lot of my teeth and eventually had to be assessed by an ENT (ear/nose and throat specialist) who injected Botox into my oesophagus to ease the oesophageal stricture so that I could swallow foods. I fell, down a particularly steep slope at our trailer at Birch Bay, landing right on my head and breaking three ribs. I struggled with pain in my right forehead, right neck and right shoulder. My physician taught my husband to administer Lidocaine injections into the back of my neck at the hairline and into my shoulder muscle. This actually stopped the pain for a while, but why could they not figure out what was causing it? I made trips to an acupuncturist, a kinesiologist, and a physiotherapist. They were all convinced they had the answer. People at the pain clinic at St. Paul’s Hospital convinced me that it was connected to the brain and the tardive dyskinesia damage but all they had to offer me was drugs and even marijuana cookies. It is hard to make marijuana cookies without flour and they really stink up your kitchen. Since my husband made them for me he ended up getting high and did not enjoy the experience. Come to think of it, neither did I. People at the U.B.C. Movement Disorder Clinic convinced me that I had dystonia on the upper right part of my body. An impairment of the muscular tonus I was told, and “wow” there was a specialist at the Vancouver Hospital who was doing wonders with this problem. It involved drilling two holes in the top of the head, while you are awake, but with freezing around the area, inserting leads down into a box placed in the stomach. To say this was unpleasant puts it mildly. When my husband saw me prior to surgery with this helmet screwed to my forehead he cried. When they turned the machine on I received electric shocks down my arms. We tried this numerous times. Both the doctor and his assistant thought I was just saying this because I did not like the appearance of the holes in my head or the leads down my chest or the box in my stomach. We did blind studies where my husband would not tell me when he turned the “box” on. To no avail! I would have done anything to rid myself of yet another dreaded pain! I needed to see an internist and two psychiatrists in order to have the box and leads removed from my body. I passed the psychiatric tests to my amazement and the box and I parted company. I was then seen by another pain clinic specialist who felt I had a trapped nerve from the fall. When you fall on your head, a heavy object, it can trap a nerve in the neck, particularly at the C1/2 level. His test proved positive and he referred me to one of only two anaesthesiologists in B.C. who do the procedure called radio frequency lesioning. I had the first surgery last September. Because of my weight, which was now only 82 pounds, he felt he should not turn the machine up to the highest setting. They call this pulse radio frequency lesioning. Now aren’t you learning a lot from this article about celiac disease and dermatitis herpetiformis? I was wrapped in ice for two months but sadly the procedure failed. I was told that it needed to be turned to the highest setting. January 4th the procedure was repeated. The insertion of a needle into the spine while one is awake is also unpleasant needless to say, but I was desperate. I was again packed in ice until February when life began to look pretty good. Wow! Clothes did not fit me and there was a whole world of shopping out there to do! I had become slothful with my celiac diet, licking envelopes when I knew the glue contained flour, baking goodies for my family and sifting flour of all things. To counteract the appearance of DH spots in my scalp, horrid armies of them, I did the 5-4-3-2-1 treatment. However, I had been using Lidocaine injections for the pain in my neck. I found I could not climb stairs without becoming breathless. I was confused and weak. “Likely from two surgeries” I told myself. My husband commented that my skin was grey and my lips blue. I attended my general physician - another one. Oh my, I dread even telling you this! He thought I might have sleep apnoea. My husband picked up the machine for the test for two days. He dropped it off at 10:15 A.M. and by noon hour the oxygen people were back at our house with an oxygen tank. I was told my GP was going to refer me urgently to an internist. I dragged the lead of this oxygen tank around with me for a week until my husband became angry. He went himself to see my GP who went “next door” in his building to the Internist who saw me the next day, Saturday. Upon taking my history she suspected that I had Methemoglobinemia and suggested we both walk over to the hospital next door right away. I was put in the I.C.U. and given oxygen. After numerous blood tests were taken my Methemoglobinemia results came back at 26.5. Death occurs at 40 which could have been within a week to ten days. I was given methylene blue. It was flushed through my veins and it burned like a hot iron! I was given two units of packed red cells. For you celiacs with dermatitis herpetiformis, methemoglobinemia is when the blood is converted to another chemical that cannot deliver oxygen to tissues, called Methemoglobin. It was explained to me that it was like all the oxygen in my blood was put in a closet with the door locked. They took me off my beloved Dapsone but after three days the spots were back and as bad as when I was first diagnosed, all over my arms and legs, scalp and even face. So I was put back on the Dapsone with strict instructions not to use Lidocaine, and given a list of other drugs and foods that can cause Methemoglobinemia, like Benzocaine and Prilocaine, and even some cold cuts with nitrates in them. Upon discharge we were fearful that this would happen again so my husband purchased a mini SAT (oxygen saturation) machine from a medical store that sells on the Internet. It is the cutest little machine! You stick your finger into its jaw and it tells your SAT level as well as your pulse rate. For just $39.99 you cannot beat it. March was our anniversary and our children felt we needed to celebrate. They bought one of these mid-week packages to the Harrison Hot Springs Hotel, with dinners included. We do not go out for meals because I am embarrassed at the inquisition I have to give the waitress each time. We were reassured the first night that there was no gluten in my meal - none whatsoever. Ha! I was up all night! You know the drill. By noon hour the next day I was so sick and my SAT levels kept dropping. A normal SAT level should be about 98, mine is normally 92, but it went from 92, to 87 to 83 until my husband said, “Let’s go”. We drove home to our hospital. Doctors there are now familiar with my problem. But this time I had pneumonia and other abnormal blood levels. It turned out that I had the type of pneumonia that is caused by swallowing food into the lungs. That was from all the vomiting I had done the previous night of course. I was admitted to hospital for eight days this time. That ended in April. I am now able to take Dapsone, but in conjunction with Cimetidine, which is actually a drug for gastritis or ulcers. I still check my SAT level weekly and have been told if it drops below 90 I am to go to the hospital for testing. I am fearful of restaurants because so much of their food products come in large tins and they don’t know what ingredients are in them. When I find a restaurant I can trust, I telephone the Vancouver chapter of the Canadian Celiac Association and tell them. There are two stores I know that sell gluten free foods and even a bakery in Vancouver close to where my daughter works, but mostly I make my own gluten free recipes. The hospital dietician had so little information on celiac disease and recipes she asked me to fax her some of my information and recipes. I have become the “Betty Crocker” of celiac food and the “know” person for DH, trapped nerves and a barrage of diseases and problems that I did not have. Health nightmares? I have had enough and want to get back to my garden and my love of writing. I deserve it!
  12. Gini Warner

    Clumsiness and Imbalance

    Celiac.com 12/29/2018 - Imbalance and clumsiness may not be the most common symptom of the nervous system related to gluten intolerance but one of the most researched areas. Physicians use the term “ataxia” to describe poor coordination and balance. It can affect your walking and your ability to stand. While many systems contribute to your balance your cerebellum in the brain is the location that organizes all of the information and navigates your movements precisely. Some doctors claim that ataxia is one of the most common disorders produced by gluten in relationship to our nervous system. Poor coordination and clumsiness does occur with gluten intolerance and affects children as well as adults. Evidence suggests that this is all due to the immune system’s reaction to gluten itself. In people who are genetically at-risk for gluten sensitivity, gluten induces an immune attack against the protein gliadin and this antibody not only attacks gliadin in the gut but also attacks tissues far away from the intestines. In this case, through the bloodstream, these antibodies travel to the cerebellum and attack the Purkinje cells. As these cells become inflamed from the immune attack, the ability to integrate all the “balance information” is impaired, and coordination suffers. Symptoms like poor balance and coordination can result. A study in Britain examined 224 people with ataxia disorders. Some had an inherited disorder of ataxia, some had ataxia combined with other neurologic symptoms, and some simply had ataxia without known cause. Of those that were without known cause, 41 percent were found to have anti-gliadin antibodies supporting gluten sensitivity as a cause. In another study, ten patients with headaches and/or clumsiness were placed on a gluten-free diet. Over time, nine of the ten showed a beneficial response in all symptoms. The evidence is overwhelming. The presence of gluten antibodies, shrinkage of the cerebellum and the dramatic response to dietary change all support gluten as the cause.
  13. Celiac.com 01/01/2019 - 2018 was a very good year for people with celiac disease and gluten intolerance. There were a number of notable developments and breakthroughs this year, including major progress on a celiac disease vaccine, the fast-tracking of Timp-Glia, a drug for treating a celiac disease symptoms, and a new blood test that can spot celiac disease without the patient being forced to eat gluten beforehand. 2018 also brought us revelations that homemade yogurt can help to heal irritable bowel symptoms in most people; that people with autism have celiac disease rates twenty-times higher than the general population; that one in three restaurant food labeled ‘gluten-free’ may contain gluten; and that people with celiac disease are bad at judging gluten-exposure. In all, 2018 brought us numerous stories that can help us manage our celiac disease and to make better, smarter, gluten-free food decisions. Here are Celiac.com’s most popular stories of 2018: New Blood Test Will Spot Celiac Disease Without Gluten Consumption Fifteen Symptoms that can Make Celiac Disease Hard to Diagnose Who Makes America's Best Gluten-Free Pizza? Celiac Disease Rates 20 Times Higher in People with Autism 15 Foods People Wrongly Think Are Gluten-Free Starbucks Dumps Gluten-Free Breakfast Sandwich Promising Celiac Vaccine Nexvax2 Begins Phase Two Trials Celiac Disease Treatment TIMP-GLIA Wins Fast Track Status Gluten-Free Halloween Candy List for 2018 Homemade Yogurt Resolves Irritable Bowel Symptoms in Most Patients Gluten Insensitivity? Party City Stumbles with Offensive Pre-Super Bowl Ad Being Too Vigilant About Gluten-Free Diet Causes Stress in Teens and Adults with Celiac Disease Celiac.com’s 25 Most Popular Gluten-Free Dessert Recipes New Study Says One in Three 'Gluten-Free' Restaurant Foods Contain Gluten Celiac Patients Are Bad at Judging Gluten Exposure Based on Symptoms We hope you enjoyed this review of our most popular celiac and gluten-free articles for 2018. We look forward to bringing you more important information and breaking news and stories about celiac disease and gluten-free living in the New Year. Happy Holidays!
  14. 2018 was a very good year for people with celiac disease and gluten intolerance. There were a number of notable developments and breakthroughs this year, including major progress on a celiac disease vaccine, the fast-tracking of Timp-Glia, a drug for treating a celiac disease symptoms, and a new blood test that can spot celiac disease without the patient being forced to eat gluten beforehand. 2018 also brought us revelations that homemade yogurt can help to heal irritable bowel symptoms in most people; that people with autism have celiac disease rates twenty-times higher than the general population; that one in three restaurant food labeled ‘gluten-free’ may contain gluten; and that people with celiac disease are bad at judging gluten-exposure. In all, 2018 brought us numerous stories that can help us manage our celiac disease and to make better, smarter, gluten-free food decisions. Here are Celiac.com’s most popular stories of 2018: New Blood Test Will Spot Celiac Disease Without Gluten Consumption https://www.celiac.com/articles.html/celiac-disease-diagnosis-testing-amp-treatment/new-blood-test-will-spot-celiac-disease-without-gluten-consumption-r4328/ Fifteen Symptoms that can Make Celiac Disease Hard to Diagnose https://www.celiac.com/articles.html/journal-of-gluten-sensitivity/journal-of-gluten-sensitivity-spring-2018-issue/fifteen-symptoms-that-can-make-celiac-disease-hard-to-diagnose-r4387/ Who Makes America's Best Gluten-Free Pizza? https://www.celiac.com/articles.html/miscellaneous-information-on-celiac-disease/conferences-publicity-pregnancy-church-bread-machines-distillation-beer/who-makes-america039s-best-gluten-free-pizza-r4318/ Celiac Disease Rates 20 Times Higher in People with Autism https://www.celiac.com/articles.html/celiac-disease-amp-related-diseases-and-disorders/autism-and-celiac-disease/celiac-disease-rates-20-times-higher-in-people-with-autism-r4588/ 15 Foods People Wrongly Think Are Gluten-Free https://www.celiac.com/articles.html/miscellaneous-information-on-celiac-disease/additional-celiac-disease-concerns/15-foods-people-wrongly-think-are-gluten-free-r4595/ Starbucks Dumps Gluten-Free Breakfast Sandwich https://www.celiac.com/articles.html/miscellaneous-information-on-celiac-disease/additional-celiac-disease-concerns/starbucks-dumps-gluten-free-breakfast-sandwich-r4454/ Promising Celiac Vaccine Nexvax2 Begins Phase Two Trials https://www.celiac.com/articles.html/celiac-disease-diagnosis-testing-amp-treatment/promising-celiac-vaccine-nexvax2-begins-phase-two-trials-r4615/ Celiac Disease Treatment TIMP-GLIA Wins Fast Track Status https://www.celiac.com/articles.html/celiac-disease-diagnosis-testing-amp-treatment/celiac-disease-treatment-timp-glia-wins-fast-track-status-r4338/ Gluten-Free Halloween Candy List for 2018 https://www.celiac.com/articles.html/journal-of-gluten-sensitivity/journal-of-gluten-sensitivity-autumn-2018-issue/gluten-free-halloween-candy-list-for-2018-r4589/ Homemade Yogurt Resolves Irritable Bowel Symptoms in Most Patients https://www.celiac.com/articles.html/celiac-disease-amp-related-diseases-and-disorders/irritable-bowel-syndrome-and-celiac-disease/homemade-yogurt-resolves-irritable-bowel-symptoms-in-most-patients-r4325/ Gluten Insensitivity? Party City Stumbles with Offensive Pre-Super Bowl Ad https://www.celiac.com/articles.html/miscellaneous-information-on-celiac-disease/additional-celiac-disease-concerns/gluten-insensitivity-party-city-stumbles-with-offensive-pre-super-bowl-ad-r4335/ Being Too Vigilant About Gluten-Free Diet Causes Stress in Teens and Adults with Celiac Disease https://www.celiac.com/articles.html/celiac-disease-gluten-intolerance-research/being-too-vigilant-about-gluten-free-diet-causes-stress-in-teens-and-adults-with-celiac-disease-r4356/ Celiac.com’s 25 Most Popular Gluten-Free Dessert Recipes https://www.celiac.com/articles.html/gluten-free-cooking/celiaccom’s-25-most-popular-gluten-free-dessert-recipes-r4543/ New Study Says One in Three 'Gluten-Free' Restaurant Foods Contain Gluten https://www.celiac.com/articles.html/miscellaneous-information-on-celiac-disease/additional-celiac-disease-concerns/new-study-says-one-in-three-gluten-free-restaurant-foods contain-gluten-r4593/ Celiac Patients Are Bad at Judging Gluten Exposure Based on Symptoms https://www.celiac.com/articles.html/celiac-disease-gluten-intolerance-research/celiac-patients-are-bad-at-judging-gluten-exposure-based-on-symptoms-r4627/ We hope you enjoyed this review of our most popular celiac and gluten-free articles for 2018. We look forward to bringing you more important information and breaking news and stories about celiac disease and gluten-free living in the New Year. Happy Holidays!
  15. Celiac.com 12/28/2018 - Beyond a few teaser studies, we don’t know enough about whether the individual micro-biome might play a role in the development of celiac disease and inflammatory bowel disease. Top celiac researcher Alessio Fasano, together with colleague G. Serena, recently presented an overview of current knowledge regarding the contribution of the individual micro-biome to celiac disease and inflammatory bowel disease. Their discussion includes a particular focus on how probiotics may be used as potential preventive therapy for CIDs. They are both affiliated with the Mucosal Immunology and Biology Research Center and Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital for Children - Harvard Medical School, Boston, MA, USA. As part of their presentation, they write that, globally, cases of chronic inflammatory diseases (CIDs) are undergoing a steep rise. This rise, together with limited effective strategies for slowing these disease explosions demands deeper knowledge of their physical mechanisms in order to reduce the adverse effects of the diseases on children. Several cross-sectional studies have shown a connection between intestinal microbial imbalance and active disease. Unfortunately, they note, these studies do not demonstrate any connection between changes in microflora as a factor in disease development, and so do not suggest any promising directions to explore for possible treatments. Fasano and Serena say that additional studies are needed to show conclusively whether intestinal dysbiosis plays a part in triggering CIDs. Furthermore, given the complexity of the microflora interaction with the host, it is necessary to design a systems-level model of interactions between the host and the development of disease by integrating micro-biome, metagenomics, metatranscriptomics, and metabolomics with either clinical or environmental data. In their overview, Fasano and Serena discuss the current knowledge regarding the contribution of the individual microbiome to celiac disease and inflammatory bowel disease. Their discussion includes a particular focus on how probiotics may be used as potential preventive therapy for CIDs. The article includes a paywall, but you may find it at: Adv Exp Med Biol. 2018 Dec 20. doi: 10.1007/5584_2018_317
  16. Celiac.com 12/24/2018 - People with celiac disease, including adults with subclinical celiac disease, have low bone mineral density (BMD), deteriorated bone microarchitecture and meta-analysis show an increased risk of fracture. Immunoglobulin A (IgA) against transglutaminase 2 (IgA TG2) is a highly reliable marker to detect celiac disease. A team of researchers recently set out to explore the prevalence of positive IgA TG2 and celiac disease in patients with distal radius and ankle fracture compared to community-based controls. For their study case-controlled study, the researchers enrolled our hundred patients aged 40 years or above with distal fractures. The team used the National Population Registry to identify about 197 control subjects who had never suffered a fracture. The team measured BMD, and noted any comorbidities, medications, physical activity, smoking habits, body mass index (BMI) and nutritional factors. Blood analysis to detect common causes of secondary osteoporosis was performed. They found that about 2.5% of the fracture patients had positive IgA TG2, compared to 1% in the control group. The odds ratio, adjusted for sex and age, of having positive IgA TG2 was 2.50 (95% CI 0.54–11.56). They found that patients with fractures had no significantly greater odds of celiac disease than control subjects. However, results do indicate that positive IgA TG2 is more common in fracture patients than in control subjects. This study does not point to any need for universal screening for celiac disease in fracture patients, but it does support the current clinical practice in Norway of looking for celiac disease in patients with fracture, osteoporosis and other risk factors for celiac disease. Read more at Tandfonline.com https://doi.org/10.1080/00365521.2018.1509122 The research team included Anja M. Hjelle, Ellen Apalset, Pawel Mielnik, Roy M. Nilsen, Knut E. A. Lundin & Grethe S. Tell. They are variously affiliated with the the Department of Rheumatology, Division of Medicine, District General Hospital of Førde, Førde, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; the Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; the Bergen group of Epidemiology and Biomarkers in Rheumatic Disease (BeABird), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway; the Department of Rheumatology, Division of Medicine, District General Hospital of Førde, Førde, Norway; the Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway; the Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway; KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway; and the Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
  17. Celiac.com 12/21/2018 - For most celiac patients, treatment with the gluten-free diet marks the turning point for their health. It can take a few months for the villi of the small intestine to heal, but eventually the villi are able to absorb the nutrients in their food and the symptoms of celiac disease are alleviated. Unfortunately, there are some celiacs who don’t respond to the gluten-free diet. This is the only current treatment for the disease, resulting in a condition known as refractory celiac disease or nonresponsive celiac disease (NRCD). Although celiac experts have stated that actual refractory celiac disease, wherein damage to the small intestine is irreversible, is rare, a preliminary study reported by Med Page Today suggests that the condition is more common than the medical community once thought. Fortunately, the study also showed that refractory celiac disease patients did respond favorably to medical treatment. Celiac disease, an autoimmune disease caused by gluten, a protein found in wheat, barley, and rye, affects three million Americans, or about 1% of the U.S. population. Patients with refractory celiac disease experience abdominal pain, severe malabsorption of nutrients, and intestinal damage. A single-center preliminary study suggests that “more patients with celiac disease may stop responding to their gluten-free diets,” as reported by Med Page Today. The researchers studied non-responsive celiac patients treated at the University of Virginia Medical Center over the past decade. According to Med Page Today, “Overall, patients were diagnosed with refractive disease a mean of 4.7 years following their initial diagnosis of celiac disease.” Furthermore, diagnoses of refractory celiac seemed to occur more recently, mostly within the last five years and almost half of them within the last six months. The researchers, including Christopher Hammerle, MD, and Sheila Crowe, MD, of the University of Virginia in Charlottesville, found that the refractory celiac disease patients did respond to treatment with thiopurines. “These agents are my treatment-of-choice for refractory celiac disease to avoid long-term steroids,” Hammerle told MedPage Today. According to Shailaja Jamma, MD, and Daniel Leffler, MD, MS, in Real Life with Celiac Disease, there could be many explanations for a failure to respond favorably to the gluten-free diet. In their chapter on NRCD, they write, “you would need to be on a GFD for at least 6 months without significant improvement before we would decide that you were not responding and look for other reasons.” This is due to the fact that recovery times vary from person to person, and as long as patient seems to be improving continually over time, no matter the speed, non-responsive celiac disease is usually an unnecessary label. Jamma and Leffler found that the most common causes—designated “very common’—are gluten exposure and Irritable Bowel Syndrome (IBS). The next most common causes of NRCD, labeled as “somewhat common,” are lactose intolerance or fructose malabsorption, microscopic colitis, and small intestinal bacterial overgrowth. “Rare” causes include actual refractory celiac disease, which can be confirmed with a biopsy of the small intestine, an eating disorder, inflammatory bowel disease, which can also be confirmed with a biopsy as well as imaging studies of the small or large intestine, pancreatic exocrine insufficiency, and motility disturbances, that is, when food moves too quickly or too slowly through the intestine. Finally, food allergy and cancer are “very rare” causes of NCRD. According to the Mayo Clinic, as reported by Celiac.com, “gluten contamination is the leading reason for non-responsive celiac disease,” and estimates that 18% of non-responsive celiac disease cases are due to actual refractory celiac disease. The Mayo Clinic researchers recommend that before making a refractory celiac disease diagnosis, additional diseases as well as gluten contamination should be ruled out as causes. According to Jamma and Leffler, “The first step is often to get confirmation that you do indeed have celiac disease,” since “celiac disease can be mistakenly diagnosed when the true problem is something else.” Med Page Today points out that most of the patients with refractory celiac disease responded favorably to a thiopurine medication rather than the conventional method of treatment for the condition, steroids. This form of treatment doesn’t carry with it the risk of steroid dependence. If you have some concerns regarding your response to the gluten-free diet, it’s recommended that you talk with your doctor about a non-responsive celiac disease evaluation. An evaluation of your diet may very well confirm that you are still ingesting gluten, but if this isn’t the case, other causes can be explored by your doctor. Thiopurine seems promising as a treatment option for those who do, in fact, have actual refractory disease. Resources: 1. About.com: Refractory (Unresponsive) Celiac Disease 2. Celiac.com: Causes of Non-responsive Celiac Disease - More than 50% Continue to Ingest Gluten Unknowingly. 3. Jamma, Shailaja, MD, and Leffler, Daniel A, MD. “Nonresponsive Celiac Disease.” Real Life with Celiac Disease: AGA Press, 2010. 4. Medpage Today: ACG: More Celiac Disease May Be Refractory
  18. Celiac.com 12/17/2018 - A 39-year-old woman with possible celiac disease was left brain dead after a dangerous internet “soy sauce colon cleanse” caused critically high levels of salt in her blood, which led to organ failure and death. The medical YouTube channel Chubbyemu, says that the woman, identified only by the initials, CG, arrived at the emergency room with a rapidly deteriorating mental status. Earlier that day, CG had performed a “soy sauce colon cleanse,” a dangerous internet fad in which people drink an entire liter of soy sauce in two hours. CG had been unwell for weeks before the incident. She had begun a diet made up exclusively of white bread and canned fish six months prior, and had lost 11kg, nearly 25 pounds, in the three weeks leading up to the soy sauce incident. Additionally, CG had been recently diagnosed with untreatable paranoid schizophrenia. She suffered from a psychosis that caused her to believe the government had poisoned her. Somewhere online, she read that the soy sauce colon “cleanse” would purge the toxins form her body. There are indications that CG may have suffered from celiac disease. Soon after drinking the highly salt-laden soy sauce her heart began to beat rapidly, according to a person identified only as Bernard, who claims to be a U.S.-based medical doctor, and who runs the popular Chubbyemu channel, which features videos on medical issues like kidney disease and cancer. After resisting all attempts to get her to drink water, CG began to stumble around and and mumble unintelligibly until she collapsed. She was rushed to a hospital and while en route went into cardiac arrest, before being resuscitated. Eventually, though, CG died as a result of acute hypernatremia— extremely high levels of salt in the blood. Bernard believes the woman had undiagnosed celiac disease, which manifested as psychosis and delusional disorder. He adds that a microscopic examination of her cells revealed “marked villous blunting and atrophy”, a common sign of celiac disease. Bernard argued she developed gluten sensitivity, became delusional and was misdiagnosed, and later falling victim to internet misinformation. If that is true, then the story is a sad one, indeed. In any case, the dangers of drinking large amounts of soy sauce or any other salty substance can hardly be overstated. Be very careful and always seek out the advice of a doctor before beginning any type of “cleanse” or “purge” meant to rid the body of “toxins.” See the video on the YouTube Channel Chubbyemu. Read more at: News.com.au
  19. Celiac.com 12/20/2018 - Patients with monoglandular and/or polyglandular autoimmunity, and their relatives, have higher rates of celiac disease than those without such autoimmunity. Somewhere between 10 and 30% of patients with celiac disease test positive for thyroid and/or type 1 diabetes antibodies, while around 5 to 7% of patients with autoimmune thyroid disease and/or type 1 diabetes test positive for IgA anti-tissue transglutaminase antibodies. A team of researchers recently set out to examine the relationship between celiac disease and endocrine autoimmunity. The research team included George J. Kahalya, Lara Frommera, and Detlef Schuppan. They are variously affiliated with the Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany, the Institute for Translational Immunology and Research Center for Immunotherapy (FZI), Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany, and the Division of Gastroenterology and the Deaconess Medical Center, Harvard Medical School, Boston, MA, United States. Celiac disease and endocrine autoimmunity do share a common genetic background, which definitely explains some of the relationship. The main common denominators are HLA antigens DQ2 (DQA1*0501-DQB1*0201) and/or DQ8 (DQA1*0301-DQB1*0302), that are tightly linked to DR3 and DR4, respectively. Researchers have identified functional single nucleotide polymorphisms of various genes involved in immune regulation as susceptibility genes for both celiac disease and monoglandular or polyglandular autoimmunity. This is a promising hypothesis, but exactly how the effects of a gluten-free diet might prevent or ameliorate glandular autoimmunity remains unclear. Based on their results, the research team does recommend that all patients with celiac disease be tested for type 1 diabetes and/or autoimmune thyroid disease. They also recommend that patients with the above autoimmune endocrine disorders be checked for celiac disease. Read more at: Sciencedirect.com https://doi.org/10.1016/j.autrev.2018.05.013
  20. Celiac.com 12/18/2018 - Prescriptions for gluten-free food will no longer be part of the UK’s vaunted national health care program in all places, due in part to the widespread availability of gluten-free foods at regular markets, and the high costs of maintaining the program. Starting Monday, December 3rd, 2018, gluten-free food will no longer be routinely available on prescription from any GP practice in the "Greater Nottingham" region for patients with celiac disease or dermatitis herpetiformis: a skin condition linked to celiac disease. Patients with such prescriptions, including children, will be notified by mail of the pending changes, and will receive information, help and support for managing their gluten-free diets. Coming at a time of "severe financial pressures", the decision ostensibly concerns patients in Nottingham, Rushcliffe, Gedling, Broxtowe and Hucknall, where patients were eligible for a mix of bread and flour each month. In the city, patients could get a range of products like bread, pasta, mix and cereal. Explaining the decision, Dr Hugh Porter, chair of the Nottingham City Clinical Commissioning Group, said "The cost to the NHS of a loaf of gluten-free bread is much higher than those bought in a supermarket.” Dr. Porter also adds that the Commissioning Group is planning a detailed evaluation process “to assess the effects of these changes over the coming year."
  21. Celiac.com 12/08/2018 - Recently CNN published an article entitled “Will a Gluten Free Diet Improve Your Health?” Honestly there were a lot of plus-points to this article. But unfortunately the negatives could very well outweigh them if you’re considering, or are new to, the gluten-free diet. Let’s review the positives and negatives as they appear in the article: 1. Dr Leffler from Harvard Medical School was quoted as saying that: “Gluten is fairly indigestible in all people.” “There’s probably some kind of gluten intolerance in all of us.” Bravo! I was very excited to read this remark. Although I often promote this information, I haven’t heard it from others aside from Dr. Fasano. The fact that humans can’t properly digest gluten is an important truth that should be better known and more widely taught. 2. Experts now believe that celiac disease represents just one extreme of a broad spectrum of gluten intolerance that includes millions of people. It can sometimes be interesting when unnamed “experts” are quoted, but in this case I agree. I’ve often written about my belief that celiac disease to gluten sensitivity is likely one spectrum. The fact that those with gluten sensitivity don’t undergo the outright destruction of the small intestine as in the case of celiac disease, in no way puts gluten sensitivity in a less serious category. It’s a “different” reaction but no less serious. 3. They go on to state that people with celiac disease and gluten sensitivity usually have stomach aches, gas, and diarrhea -- as do people with IBS. “Usually” is not the case and it would give someone without digestive complaints a false sense that they do not have gluten intolerance. In fact, according to research, for every person with celiac disease who experiences digestive symptoms, there are eight without digestive complaints. This is why, all too often, people continue to live with migraines, depression, infertility, skin problems, obesity and autoimmune disease that is gluten related but the gluten connection remains undiagnosed because they have no digestive complaints. Let’s not kid ourselves. We’re only diagnosing, at best, seven percent of the celiacs in our country. In our medically advanced society, missing over ninety percent of those suffering with the most common lifelong disorder in the US and Europe, is beyond pitiful. Unfortunately, it is statements such as the above, limiting our focus to digestive complaints that are partly to blame for our poor rate of diagnosis. 4. Gluten sensitivity, on the other hand, is a gray area that “lacks any defining medical tests,” Leffler says. People who fall into this group exhibit the classic symptoms of celiac disease yet have no detectable intestinal damage, and test negative for certain key antibodies (though in some cases they may have elevated levels of others). The issue here might be “medical tests” and Dr. Leffler may not know about the gluten sensitivity tests that are available. However, they are available and they have recently taken a nice jump in sensitivity due to a new lab in the US (Cyrex Labs – again, I have no affiliation with this lab). I also take umbrage to the reference to the lab tests as almost an afterthought in parentheses. The truth lies within those parentheses – gluten sensitive individuals do show elevation of key antibodies that are different than those seen in celiac disease. Does that make those elevations somehow less important? Of course not! They are just different. 5. “A recent study by Fasano and his colleagues offers some clues about what gluten sensitivity is, and how it differs from celiac disease. Although they show no signs of erosion or other damage, the study found, the intestines of gluten-sensitive patients contain proteins that contribute to a harmful immune response, one that resembles -- but is distinct from -- the process underlying celiac disease. “ This is a very good point. First, Dr Fasano is spending his time researching gluten sensitivity. This is not something we would have seen several years ago. His latest research showed that the immune system DOES create a harmful immune response in the intestines of those suffering from gluten sensitivity. Is it the same response as that seen in celiacs? No. But we didn’t expect that it would be. We know that small intestinal erosion doesn’t happen in the gluten sensitive patient. What’s earth shattering about this research finding is that it completely validates what I and other clinicians like me have been saying for several years – gluten sensitivity is the adverse effect of the body’s immune system having a deleterious reaction to gluten. This research proves that point. 6. “Recommendations for people with gluten sensitivity aren’t as clear-cut. Unlike celiac disease, gluten sensitivity hasn’t been linked to intestine damage and long-term health problems, so some experts say that people on the less severe end of the spectrum should feel comfortable eating as much gluten as they can handle without feeling sick.” Ah, so easy to write, so hard to take back or explain. This is a dangerous couple of sentences. Let’s dissect: They join “intestine damage” with “long-term health problems” as if it were impossible to have a long-term health problem without intestinal damage. Nothing could be further from the truth! I have many, many patients with gluten sensitivity, and therefore none of the intestinal destruction seen with celiac disease, who would beg to differ as regards long-term health problems being associated with gluten sensitivity, not just celiac disease. These patients have seen their serious long-term health problems resolve as a result of eliminating gluten from their diet. And they did not have celiac disease. Is schizophrenia a health problem? What about migraines? How about eczema? Is infertility a health problem when you’re trying to get pregnant? What about depression? I could go on and on. And it’s not just my opinion or my patients’ opinions. This is very well substantiated by research. You cannot “feel” damage and inflammation to certain organs of your body. In fact, autoimmune disease markers can be present for well over a decade before the first symptoms show themselves. Should we wait? Is that smart? Let’s continue: In the last sentence of point #6 above, we come across those unnamed “experts” I was referring to earlier. I would really like to know names on this one. Perhaps they were misquoted, or misunderstood. The truth of the matter is that gluten is not called the “great masquerader” because it creates overt symptoms all the time, quite the contrary. That is why one never is quite sure what symptoms will improve until one actually embarks on a gluten-free diet. In fact it was this realization that caused us to write the book “The Gluten Effect” two years ago. There was little appreciation at that time of all the effects that gluten could create in the non-celiac individual, which is why we were compelled to share our experiences. 7. “Some people can be exquisitely sensitive and have to be as strict as people with celiac disease, while others can eat a pizza,” Fasano says. [he was referring to gluten sensitivity] You might imagine that a newly diagnosed individual might very well read this sentence and be keeping their fingers crossed that they might be one of the lucky ones who could eat the pizza. I am a huge fan of Dr. Fasano’s and to give this quote the benefit of the doubt I’m going to give you my interpretation. I have patients who have gone out and eaten pizza and “felt fine”. In fact they seemed to feel so “fine” that they did it again. Did they ultimately end up fine? No, they did not. They found themselves days, weeks or months later quite ill, not only with old symptoms returning but often with new ones as well. What, then, could Dr. Fasano have meant by his comment? I believe that he was trying to make a point about the difference between a celiac and a person with gluten sensitivity. A celiac could have a miniscule amount of a crouton drop into their salad and be very ill almost immediately, while a person with gluten sensitivity would not necessarily have such an acute reaction. But to take that to mean that it is in some way “fine” or healthy for them to eat gluten is definitely not the case and I don’t believe that’s what Dr. Fasano meant. 8. “If you suspect your body can’t tolerate gluten, the first thing you should do is get tested for celiac disease. If the test comes back negative, try a gluten-free diet for a week to see if you feel better, Leffler says.” The cells in the intestine take about a month to turn over and renew themselves. A week on a gluten-free diet is not sufficient, in the main, to determine whether one has a problem. A month of absolutely no gluten is a more appropriate standard. With that said, some people do feel better almost immediately but I wouldn’t want to miss those who take several weeks to feel the change by not pointing out the 30 day recommendation. 9. Finally, ending on an up note: “People with gluten sensitivity who don’t respond this way [meaning feeling ill immediately] aren’t necessarily in the clear, however. Experts like Marlisa Brown, a registered dietitian and author worry that gluten could have long-term negative consequences that just haven’t been identified yet.” As we’ve been discussing many of the consequences are known and they are serious. But I do agree with her that just because you don’t feel sick right away is no reason to eat gluten when you are sensitive to it. I hope this helps clarify this recent article and gives you and those you care about the support you need to continue your gluten-free lifestyle. It is worth it, I promise! References: www.CyrexLabs.com www.Enterolab.com Alimentary Pharmacology & Therapeutics. 2009 Jun 15;29(12):1299-308. Epub 2009 Mar 3.
  22. Celiac.com 12/12/2018 - In a step that health officials say could provide immediate relief to the estimated eight million Indians who suffer from celiac disease, the Indian government is assessing a plan to require drugmakers to declare any gluten ingredients on medical labels. India’s chief drug advisory body will discuss the issue at its meeting scheduled in early December, said people with knowledge of the plan. The Drug Technical Advisory Board’s decision to address the issue of gluten-free labels for drugs and medicine comes on the heels of an active recommendation by the department of physical medicine and rehabilitation at the All India Institute of Medical Sciences (AIIMS). In addition to clear gluten-warnings on all medical labels, experts at AIIMS have proposed changing the law to force drug makers to actively avoid gluten-containing ingredients in drugs or medicine. The proposal aligns with guidelines drafted by the US Food and Drug Administration (FDA) in 2017. Those guidelines call for drug makers to properly label medications that contain gluten. The FDA also recommends that drug makers include a voluntary statement that indicates that the product contains no gluten, or any ingredient made from wheat, barley, or rye. Proper labeling of drugs and medicines is getting a great deal of attention from regulatory bodies over the last couple of years. Look for that trend to continue and for new guidelines to drive new labeling practices for medicines containing gluten ingredients. Overall, this is an extremely positive development for anyone with celiac disease or a medical gluten-sensitivity. Until such new guidelines make it to the pharmacy, be sure to check with your pharmacist about any drug or medicine you think might contain gluten. They are in a strong position to help, and can usually get answers to such questions. Lastly, stay tuned for more news on the official labeling decision by India's Drug Technical Advisory Board. Read more at: LIVEMINT.COM