Celiac Disease (CD) Diagnosis and Whom to Screen

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1 Celiac Disease (CD) Diagnosis and Whom to Screen Maureen Leonard MD Fellow, MassGeneral Hospital for Children Twitter-Follow Follow the MGH Celiac

2 Conflicts of Interest I have no conflicts of interest to disclose

3 Diagnosis Objectives Review the Current Classic Diagnostic Algorithm Discuss Alternative Strategies For Diagnosis Consider Future Diagnostic Directions Whom to Screen Review via Case-Based Approach Highlight High Risk Groups for routine screening

4 C D p r e v a le n c e ( % ) Increased Prevalence Over Time in U.S.A. (in Line with Other Autoimmune Diseases) % % % year During the past 35 years the true prevalence of CD in USA doubled every 15 years. C. Catassi et al, Annal Med 2010

5 Serological Test Comparison Initially Screen for IgA level; If < 7 send IgG DGP Fasano & Catassi NEJM 2012;367:

6 Current Screening Algorithm Signs or symptoms concerning for Celiac Disease or pt, belonging to a high risk group IgA, IgA ttg + IgA ttg IgA <7 -IgA ttg IgG DGP - IgA ttg Duodenal biopsy Positive Negative CD unlikely Positive Celiac Disease Negative HLA, EMA Repeat ttg Other causes Persistent or concerning symptoms EGD **10% negative serology Asymptomatic Consider HLA testing in high risk groups

7 Diagnostic Gold Standard: Duodenal Biopsy

8 Diagnostic Gold Standard: Duodenal biopsy Marsh 0: Normal duodenal tissue Marsh 1: >40 Intraepithelial Lymphocytes Marsh 2: Increased lymphocytes, crypt hyperplasia, normal villi Marsh 3: Villous Blunting

9 Gluten Ingestion Is Key To A Successful Diagnosis Patients must be eating gluten for accurate serological testing and duodenal biopsy Reintroduction of gluten prior to diagnostic testing is warranted to ensure an accurate diagnosis

10 Modified Gluten Challenge Algorithm Key Points 3g of gluten Daily (1-2 slices of bread) ttg rises 28 days Aim for minimum of 6-8 weeks 3-4 months if patient is asymptomatic Leffler, Daniel, et al (2013)

11 Alternative Strategies for Diagnosis: 4 out of 5 Rule 1. History of symptoms typically associated with celiac disease. 2. Positive serological biomarkers IgA ttg or IgA EMA 3. Compatible genetics HLA-DQ2 or DQ8 alleles 4. Small intestinal biopsy showing blunting or absence of the villi (Marsh III) and CD3+ intraepithelial lymphocytosis 5. Improvement of symptoms with a gluten free diet. Catassi C+ Fasano. Am J Med. 2010

12 Alternative Strategies For Diagnosis: Do We Really Need a Biopsy In Pediatric Patients? ESPGHAN Guidelines 2012 Signs and symptoms suggestive of CD IgA ttg >10x the cutoff value IgA EMA positive at a 2 nd time point Genetics Compatible with CD HLA DQ2 or DQ8 Husby, S., et al. 2012

13 Why We Need Initial Biopsies: Alternative Treatments Are On the Horizon Type Phase Clinical trial identification Polymeric Binder P(HEMA-co-ss)-BL-7010 Phase I/II NCT Enzyme Supplementation AN- PEP Phase II NCT ALV1003 Phase IIB NCT Zonulin Inhibitor Larazotide Acetate Completed Phase IIB NCT TTG inhibitors Elafin Preclinical - DQ2 blockers Several Discovery Phase - Induction of Tolerance NexVax2 Phase 1b NCT

14 Why We Need Initial Biopsies: To Accurately Evaluate Remission Serology Cannot Predict Compliance or Remission Status ttg and EMA do not correlate with dietary compliance Hopper et al. 7/16 of Adult pts on a GFD >1 year Normal ttg and EMA Persistent villous atrophy True in adolescents as well Evaluate Healing Endoscopically Murray et. al adults 34% remission after 2 years 66% at 5 years Hopper et al % adults Marsh 0-2 after 2 years Remission between 62-85% Vehadi et al. AmGastro Hopper, AD et al. ClinGastroenterol Hepatol 2008.

15 Future Diagnostic Directions HLA DQ2/DQ8 screening as 1 st line for high risk patients Lionetti, Elena, et al. NEJM 2014

Celiac Disease Genomic Environmental Microbiome and Metabolomic Study Prospective observational study based at MGH Enrolling infants with a first degree family member with CD who have not yet been

16 Celiac Disease Genomic Environmental Microbiome and Metabolomic Study Prospective observational study based at MGH Enrolling infants with a first degree family member with CD who have not yet been introduced to solid foods (<6 months) Collection of blood, stool and clinical information until age 5 Goals: Identify the natural history of CD. Understand the environmental factors that contribute to the development of CD. Identify changes in the micobiota that can predict the onset of CD to implement early interventions to prevent CD cdgemm@mgh.harvard.edu

17 Whom To Screen

18 Case 1: Poor Growth 7y/o male with poor weight gain Picky eater, Constipation Denies any other symptoms Family history : Uncle with T1D and thyroid disease Grandfather with thyroid disease

19 Red Flag: Decreased Height Velocity

20 BMI

21 Diagnostic Workup: Static Growth CBC: HCT: 33 HgB: 9 MCV 65 Ferritin: 5 IgA level: normal IgA ttg: >300 Endoscopy with Duodenal Biopsy: Total villous atrophy Marsh 3C Diagnosis: CD

22 Follow-up: 3 months on a GFD

23 Take Home Point: Case 1 Screen patients with Static or Poor Growth Constipation Iron deficiency anemia Consider CD with a family history of associated autoimmune diseases

24 Case 2: Poor Growth 5 y/o female followed by GI for poor growth secondary to VSD and cleft lip and palate G tube placed for supplemental nutrition Denied abdominal pain, diarrhea or other symptoms ttg accidently sent : >300 Referred to us: Endoscopy consistent with Celiac Disease

25 Take Home Point: Case 2 Patients with Poor growth Not responding to therapy as expected Whether symptoms are Present or Not

26 Case: 3 Family Members Mother ttg negative Father ttg>100 EGD Confirms CD Sibling HT: 57% Wt 75% ttg>100, EGD confirms CD Adolescent F w/ abdominal pain, bloating, and fatigue HT: 87% Wt: 97% Sibling ttg negative

27 Take Home Point: Case 3 Symptomatic patients: Independent of growth parameters First Degree Family Members Symptomatic or NOT Increased Risks in Family Members 1st Degree 1:22 2 nd Degree 1:33

28 Case 4: Patient with Down Syndrome 30 y/o male with Down syndrome Diarrhea and Fatigue Diagnosed with CD based on blood and duodenal biopsy Autoimmune Thyroid Disease DEXA- bone loss Strict GFD x 10 years Presents now with continued Fatigue Recent DEXA showed ongoing bone loss

29 Ongoing Bone Loss Causes Down Syndrome Unhealthy Body Composition Low Muscle Mass Low Vitamin D Endocrine Abnormalities Low Activity Level Baptista, Fatima, Ana Varela, and Luis B. Sardinha. Osteoporosis international 16.4 (2005):

30 Strict GFD Ongoing Bone Loss:? CD 1/100 th of a piece of bread immunogenic response triggering signs and symptoms of CD Inadvertent exposure to up to 2 g of gluten per day Active Celiac Disease Underwent EGD w/ Biopsy Marsh 3 damage Gluten Contamination Elimination Diet Catassi C, et al. A 2007;85(1): Leffler DA, et al. 2008;53(6): Gibert A, et. al 2006;18(11):

31 Take Home Point: Case 4 Patients with the following should be screened Down Syndrome Fatigue Unexplained osteoporosis Autoimmune Thyroid Disease If symptoms are not improving Do not trust serology as a maker of intestinal healing or dietary compliance

32 Who Should We Consider Testing? Patients with Abdominal Pain, Diarrhea, Weight loss Constipation Osteopenia/Osteoperosis Short Stature Anemia Delayed Puberty Dental Enamel Hypoplasia Arthritis Infertility Hill, Ivor D., et al. JPGN 40.1 (2005): 1-19.

33 Populations Warranting Asymptomatic Screening % with Celiac Disease Fasano, Alessio, et al. "Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study." Archives of internal medicine (2003):

34 Thank

Novita In Tema Di Alternative Alla Dieta Aglutinata

Novita In Tema Di Alternative Alla Dieta Aglutinata Alessio Fasano, M.D. W. Allan Walker Chair in Pediatric Gastroenterology and Nutrition Professor of Pediatrics Harvard Medical School Mucosal Biology