In the Journals

Nonceliac wheat sensitivity shows long-term persistence in patients

Patients diagnosed with nonceliac wheat sensitivity continued to experience symptoms when exposed to wheat over a median study period of more than 8 years, leading researchers to conclude that the condition is persistent.

“An increasing percentage of the general population define themselves as ‘gluten-sensitive,’ but doubts persist about many aspects of nonceliac gluten sensitivity (NCGS) and its existence itself,” Antonio Carroccio, MD, of the department of internal medicine at University of Palermo, Italy, told Healio Gastroenterology. “In the absence of sensitive and specific diagnostic biomarkers for NCGS, monitoring of the patient during elimination and re-introduction of wheat by a double-blind placebo-controlled (DBPC) challenge method has been suggested as the ideal diagnostic method. Obviously, this is a cumbersome and time-consuming procedure which few studies have used.”

Carroccio and colleagues re-evaluated data on 200 patients from a previous study (mean age, 40 years; 181 women), diagnosed with NCGS by DBPC wheat challenge between 2001 and 2011, to determine if they still adhered to a wheat-free diet, and to evaluate their clinical symptoms in relation to their current diet.

A median of 8 years after their diagnosis, about 74% of patients remained on wheat-free diet, all of whom reported that involuntary wheat consumption regularly caused “IBS-like” symptoms. Of those who discontinued the wheat-free diet, 23 reported that eating wheat still triggered symptoms.

Eighty-eight percent of all patients saw improvements in their symptoms after being diagnosed with NCGS, and 98% of those who adhered to a strict gluten-free diet (n = 148) experienced symptom improvement compared with 58% of those who did not (n = 52; P < .0001).

Finally, 22 patients who remained on a wheat-free diet underwent a repeat DBPC wheat challenge, of whom 20 had a reaction.

In total, NCGS persisted in 85% of all patients.

“The improvement or very often disappearance of IBS-symptoms was observed in more than 80% of the patients who maintained a wheat-free diet; these results underline the importance of correctly identifying NCWS patients, as the elimination diet definitively resolved their symptoms, a result that no medical treatment achieves in IBS patients,” Carroccio said.

He did, however, suggest that these findings be interpreted with caution, as they only apply to patients in whom NCGS has been diagnosed.

“These findings cannot be attributed to all ‘people who avoid gluten,’” he said. “We studied a cohort of patients who had a marked immunologic component: about 90% of our patients had IEL count of >25/100 epithelial cells (EC) in the duodenal mucosa, in about 40% of our cohort we found the presence of serum anti-nuclear antibodies, and our patients had laboratory and clinical characteristics which can suggest an allergic condition. This implies that NCGS can be considered a persistent condition only in the presence of similar patient characteristics.”

He continued that for patients who do not exhibit the clinical characteristics found in this study cohort, “the well known beneficial effect of a low FODMAP diet in IBS — to which the elimination of wheat from the diet strongly contributes — must be taken into account. In these patients, wheat intolerance might not be persistent and the course of the IBS symptoms could be different.” – by Adam Leitenberger

Disclosures: The researchers report no relevant financial disclosures.

Patients diagnosed with nonceliac wheat sensitivity continued to experience symptoms when exposed to wheat over a median study period of more than 8 years, leading researchers to conclude that the condition is persistent.

“An increasing percentage of the general population define themselves as ‘gluten-sensitive,’ but doubts persist about many aspects of nonceliac gluten sensitivity (NCGS) and its existence itself,” Antonio Carroccio, MD, of the department of internal medicine at University of Palermo, Italy, told Healio Gastroenterology. “In the absence of sensitive and specific diagnostic biomarkers for NCGS, monitoring of the patient during elimination and re-introduction of wheat by a double-blind placebo-controlled (DBPC) challenge method has been suggested as the ideal diagnostic method. Obviously, this is a cumbersome and time-consuming procedure which few studies have used.”

Carroccio and colleagues re-evaluated data on 200 patients from a previous study (mean age, 40 years; 181 women), diagnosed with NCGS by DBPC wheat challenge between 2001 and 2011, to determine if they still adhered to a wheat-free diet, and to evaluate their clinical symptoms in relation to their current diet.

A median of 8 years after their diagnosis, about 74% of patients remained on wheat-free diet, all of whom reported that involuntary wheat consumption regularly caused “IBS-like” symptoms. Of those who discontinued the wheat-free diet, 23 reported that eating wheat still triggered symptoms.

Eighty-eight percent of all patients saw improvements in their symptoms after being diagnosed with NCGS, and 98% of those who adhered to a strict gluten-free diet (n = 148) experienced symptom improvement compared with 58% of those who did not (n = 52; P < .0001).

Finally, 22 patients who remained on a wheat-free diet underwent a repeat DBPC wheat challenge, of whom 20 had a reaction.

In total, NCGS persisted in 85% of all patients.

“The improvement or very often disappearance of IBS-symptoms was observed in more than 80% of the patients who maintained a wheat-free diet; these results underline the importance of correctly identifying NCWS patients, as the elimination diet definitively resolved their symptoms, a result that no medical treatment achieves in IBS patients,” Carroccio said.

He did, however, suggest that these findings be interpreted with caution, as they only apply to patients in whom NCGS has been diagnosed.

“These findings cannot be attributed to all ‘people who avoid gluten,’” he said. “We studied a cohort of patients who had a marked immunologic component: about 90% of our patients had IEL count of >25/100 epithelial cells (EC) in the duodenal mucosa, in about 40% of our cohort we found the presence of serum anti-nuclear antibodies, and our patients had laboratory and clinical characteristics which can suggest an allergic condition. This implies that NCGS can be considered a persistent condition only in the presence of similar patient characteristics.”

He continued that for patients who do not exhibit the clinical characteristics found in this study cohort, “the well known beneficial effect of a low FODMAP diet in IBS — to which the elimination of wheat from the diet strongly contributes — must be taken into account. In these patients, wheat intolerance might not be persistent and the course of the IBS symptoms could be different.” – by Adam Leitenberger

Disclosures: The researchers report no relevant financial disclosures.