Refractory CD

Re: Refractory Coeliac Disease recent publications

Posted by Charlotte, Oxford on 25/3/2011


Recent research. None of it very relevant to RCD2 I’m afraid. Chris Mulder still remains appears to remain the most active in RCD research .....

Gut doi:10.1136/gut.2009.186007 Paper
Continual Monitoring of Intraepithelial Lymphocyte Immunophenotype and Clonality Is More Important Than Snapshot Analysis in the Surveillance of Refractory Coeliac Disease Hongxiang Liu et al
Conclusions: Continual monitoring of both immunophenotype and clonality of IEL is more important than snapshot analysis for RCD diagnosis and follow-up, and could provide a useful tool for surveillance of patients at risk of EATL.
NB Professor Ming-Qing Du at Cambridge
www.path.cam.ac.uk/research/investigators/du/publications.html

radiology.rsna.org/content/early/2011/02/15/radiol.11101808.abstract
MR Enteroclysis in Refractory Celiac Disease: Proposal and Validation of a Severity Scoring System Stijn J. B. Van Weyenberg et al
Abstract
Purpose: To determine magnetic resonance (MR) enteroclysis findings in patients with uncomplicated celiac disease (CD), refractory CD (RCD) type I, and RCD type II, to develop and validate a scoring system to identify patients with RCD II and to determine the diagnostic accuracy of MR enteroclysis to detect CD-related malignancies.
Conclusion: MR enteroclysis can be used to investigate the presence of RCD II or malignancy in symptomatic patients with CD.

IBD Drug May Help Treat Refractory Celiac Disease
www.celiaccentral.org/News/News-Feeds/View-Research-News/Celiac-Disease-Research/134/month--201101/vobid--4738/
(Small intestinal release mesalamine for treatment of refractory celiac disease type 1. Jamma S, Leffler D, Dennis M, et al. J Clin Gastroenterol. 2011;45:30–33)

1/28/2011
While most celiac disease symptoms are resolved with a gluten-free diet, patients who suffer from refractory celiac disease do not find relief even after the dietary change.

Medications may be used to alleviate some of the symptoms, but most treatments are inadequate for these severe cases, according to researchers. A team at Beth Israel Deaconess Medical Center, however, may have found a new option.

Published in the Journal of Clinical Gastroenterology, a new study found that individuals with refractory celiac [RCD type 1] disease may respond to a drug typically used to treat inflammatory bowel disease such as Crohn’s disease and ulcerative colitis. The drug, small intestinal release mesalamine (SIRM), was administered to 10 patients with refractory celiac disease. Six of the patients also took oral budesonide along with SIRM. Within 4 weeks, half of the patients reported complete symptom relief, and another individual cited partial relief. Two of the participants were able to stop using budesonide during the trial. One patient discontinued the SIRM treatment due to headaches.

The research team, which included NFCA Scientific/Medical Advisory Board Members Dan Leffler, MD, MS, and Ciaran Kelly, MD, and Ask the Dietitian’s Melinda Dennis, MS, RD, LDN, concluded that SIRM could be a safe, effective treatment for refractory celiac disease, but that additional trials would be needed.

Comment by Peter Green on this:

journals.lww.com/jcge/Fulltext/2011/01000/Mesalamine_for_Refractory_Celiac_Disease__An_Old.1.aspx
Mesalamine for Refractory Celiac Disease: An Old Medicine for a New Disease
Green, Peter H.R. MD; Lebwohl, Benjamin MD, MS

Journal of Clinical Gastroenterology: January 2011 - Volume 45 - Issue 1 - p 1–3
doi: 10.1097/MCG.0b013e3181fb4535 Editorials
Extract:
Not all patients with CD respond to the gluten-free diet. Some never respond in the first place, whereas others lose reponsiveness. The frequency of this phenomenon is unknown, and estimates of the prevalence of poorly responsive CD vary widely from 7% to 30% of all individuals with CD.12 More recently, our understanding of refractory celiac disease (RCD) has been shaped by the crucial dichotomy between RCD types 1 and 2, the latter of which has a poor short-term prognosis and is closely associated with enteropathy-associated T-cell lymphoma.13 These 2 types of RCD are differentiated by the T-cell make-up in the intestinal epithelium. A monoclonal T-cell receptor rearrangement and a loss of the normal CD3 surface expression and loss of CD4 and CD8 are indicative of RCD type 2, whereas a polyclonal T-cell receptor and normal expression of CD3/CD4/CD8 denote RCD type 1. As such, the use of immunohistochemistry, flow cytometry, and T-cell receptor polymerase chain reaction on intestinal biopsies has emerged as a valuable diagnostic and prognostic tool for assessing individuals with RCD.
Despite this advance and well-performed studies of the prognosis of RCD types 1 and 2 at referral centers,14,15 we remain ignorant of the prevalence of these conditions. Much of this uncertainty stems from the fact that patients who do not respond to the gluten-free diet do not necessarily have RCD. Some may not have CD to begin with, and others may have one of several conditions associated with CD, such as small intestinal bacterial overgrowth,16 microscopic colitis,17 and pancreatic exocrine insufficiency.18 Such conditions should be evaluated before the labeling of patients with RCD. Nevertheless, in 1 cohort of patients with or without symptoms undergoing follow-up biopsy, the proportion of patients with persistent abnormalities was found to be 34% in 5 years.19 In that cohort, the lack of histologic recovery was associated with an increased risk of death, though this did not meet statistical significance. Although that study likely overestimated the prevalence of persistent histologic abnormalities due to a selection bias, RCD type 1 may be quite common. But the issue remains understudied; the analysis of thawed serum has shown that the prevalence of CD has increased over the past 50 years,20 but we do not have a grasp of whether RCD is increasing as well.

www.docstoc.com/docs/39913459/Update-on-the-Management-of-Refractory-Coeliac-Disease NB full text

Update on the management of refractory coeliac disease.2007
Al-Toma A, Verbeek WH, Mulder CJ. J Gastrointestin Liver Dis. 2007 Mar;16(1):57-63
Department of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands.