Celiac Disease
Conditions
Keywords
celiac disease, gluten challenge
Brief summary
1. The purpose of this research study is to evaluate non-invasive markers of celiac disease activity in subjects that are on a gluten-free diet, in remission from celiac disease who undergo gluten challenge. 2. The secondary aims of this protocol are to identify novel mediators important in the pathophysiology of celiac disease and to evaluate changes in metabolism with gluten exposure.
Detailed description
The diagnosis of celiac disease carries with it important ramifications. Celiac disease is a systemic immunologic disorder in which the sentinel lesion is an enteropathy triggered by polypeptides derived primarily from the gliadin proteins found in wheat, rye and barley. Ingestion of the offending proteins leads to inflammation and intestinal mucosal damage, which results in a spectrum of abdominal symptoms, increased intestinal permeability, malabsorption, occult gastrointestinal bleeding and diarrhea. Systemic manifestations of celiac disease include a myriad of conditions including malignancy and autoimmune disease. The only accepted treatment for celiac disease is lifelong adherence to a gluten free diet. Adherence to this diet, simply put avoiding all foods containing even small amounts of wheat, rye and barley, has been shown to lead to improvement in the majority of related problems and normalization of all standard diagnostic tests. Because of this many individuals who present for evaluation of possible celiac disease but who are already on a gluten free diet cannot be tested accurately as there is currently no way of differentiating between healthy individuals and individuals with well treated celiac disease. The standard practice in such cases is to perform a 'Gluten Challenge' whereby the patient eats the equivalent of 2 slices of bread per day for six to eight weeks before returning for evaluation with serologic testing and endoscopy with duodenal biopsy. The use of the gluten challenge in clinical practice is limited by patient symptoms and resistance to such a long test period, after which it may take a number of weeks for the intestine to heal and the symptoms to resolve. Autoantibodies to tissue transglutaminase or antibodies to deamidated gliadin, while being excellent tools to predict celiac disease in patients who have been on a long-term gluten containing diet, display low sensitivities to detect short-term and/or recent gluten exposure. For this reason, it would be very useful if novel circulating markers could be identified that indicate the presence of celiac disease and in particular would provide an early and less invasive marker of a positive response to gluten challenge.
Interventions
DIETARY_SUPPLEMENTGluten
3g
Sponsors
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Beth Israel Deaconess Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
DIAGNOSTIC
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
17 Years to 72 Years
Healthy volunteers
No
Inclusion criteria
1. Age between 17 and 72 years, inclusive. 2. Subject must have been diagnosed with celiac disease by duodenal / jejunal biopsy at least 6 months prior to entrance into the study. 3. Subject has Anti-Tissue Transglutaminase (anti-tTG) ≤ 20 EU as measured by serology. 4. Subject must be on a gluten-free diet for at least the past 6 months. 5. Female subjects should be either post-menopausal (amenorrhea for at least 24 consecutive months), surgically sterile, or women of child-bearing potential (WOCP) with a negative urine beta human chorionic gonadotropin (HCG) pregnancy test prior to entering the study and who are using or agree to use acceptable methods of contraception. Abstinence is an acceptable means of avoiding pregnancy as long as the subject agrees to use contraception if they become sexually active. Acceptable contraceptives include intrauterine devices (IUDs), hormonal contraceptives (oral, depo, patch or injectable) in use for one month prior to screening and double barrier methods such as condoms or diaphragms with spermicidal gel or foam. 6. Subject must sign an Institutional Review Board approved informed consent and agree to complete required clinic visits. 7. BMI between 18.5 and 38, inclusive.
Exclusion criteria
1. Subject has Anti-Tissue Transglutaminase (anti-tTG) \> 20 EU as measured by serology. 2. Subject has other food intolerances or food allergies (other than celiac disease) that would interfere with the conduct of the study). 3. Subject has a history of severe acute symptomatic reactions to sporadic gluten ingestion 4. Subject has any chronic active GI disease other than celiac disease (e.g. Crohn's disease, IBS). 5. Subjects with symptomatic neurological or psychiatric disease(s) that would interfere with the conduct of the study. 6. Subject has clinically significant abnormal laboratory test results at the screening visit or as determined by the Principal Investigator 7. Subject is pregnant or breast feeding. 8. Subject (premenopausal females) is sexually active without contraception. 9. Subject should not have been on steroids in the past 3 months. 10. Subject is deemed inappropriate by the Principal Investigator.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Crypt Depth to Villous Height Ratio | Screening (Day -7 to -14), Day 3, Day 14 | Histological evaluation of duodenal biopsy samples to evaluate crypt depth to villous height ratio. On the best oriented section of each biopsy fragment, villous height to crypt depth (Vh:Cd) ratio was determined by measuring the mean height /mean depth of adjacent villi/proliferative crypt zones at magnification 100x. Evaluations were considered discrepant Vh:Cd differed by more than 0.5. Overall, there was excellent concordance with the evaluations of the 165 biopsy fragments determined to be optimal for evaluation. The Vh:Cd ratios on individual biopsies from a single averaged to produce a representative Vh:Cd ratio for each endoscopy. Normal Vh:Cd ratio was regarded as 3:1 or greater. Adelman DC, Murray J, Wu TT, Mäki M, Green PH, Kelly CP. Measuring Change In Small Intestinal Histology In Patients With Celiac Disease. Am J Gastroenterol. 2018 Mar;113(3):339-347. doi: 10.1038/ajg.2017.480. Epub 2018 Feb 20. Review. PubMed PMID: 29460921. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28 | LAMA evaluation has been reported to be an accurate measure of small intestinal mucosal permeability though assessment of differential absorption of lactulose and mannitol. For LAMA testing, a solution containing 7.5 g lactulose and 2 g mannitol in 100 mL of water was ingested by the participants in the evening after visit 1 and in the evening before each other study visit. The participants were asked to fast for at least 4 h and to void completely before drinking the sugar solution, then fast overnight and collect all overnight and morning urine. Urine sample analyzed for lactulose and mannitol using standardized methodology by liquid chromatography-tandem mass spectrometry. |
| Measures of Immune Activation | Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28 | IgA anti-human tissue transglutaminase assay (Inova Diagnostics, Inc., San Diego, USA): negative \<20, borderline 20-30, positive \>30. IgA/IgG anti- DGP assay : NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG. |
| Assessment of Protein Expression in Intestinal Biopsies | Screening (Day -7 to -14), Day 3, Day 14 | Proportion of participants responding to a gluten challenge. Tissue transglutaminase (tTG) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30. Deamidated gliadin peptide (DGP) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG. |
| Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | Screening (Day -7 to -14), Day 3, Day 14 | On the best oriented section of each biopsy fragment , the number of intraepithelial lymphocytes (IEL count) per 100 enterocytes was recorded at magnification 400x. IEL counts were considered discrepant if a difference of \>10 IELs existed between counts. Overall, there was excellent concordance with the evaluations of the 165 biopsy fragments determined to be optimal for evaluation. The IEL counts on individual biopsies from a single endoscopy were averaged to produce a representative IEL count for each endoscopy. Adelman DC, Murray J, Wu TT, Mäki M, Green PH, Kelly CP. Measuring Change In Small Intestinal Histology In Patients With Celiac Disease. Am J Gastroenterol. 2018 Mar;113(3):339-347. doi: 10.1038/ajg.2017.480. Epub 2018 Feb 20. Review. PubMed PMID: 29460921. |
| Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Screening (Day -7 to -14), Day 3, Day 14 | Proportion of participants responding to a gluten challenge. Tissue transglutaminase (tTG) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30. Deamidated gliadin peptide (DGP) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG. |
| Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28 | Measure Description: GSRS (Gastrointestinal Symptom Rating Scale) scores range 15-105 with higher scores indicating greater degree of symptoms GSRS: Svedlund J, Sjödin I, Dotevall G. GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Dig Dis Sci. 1988;33(2):129-134. doi:10.1007/BF01535722 |
| Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28 | CSI (Celiac Symptom Index) scores range from 7-80. Higher scores indicate greater degree of symptoms CSI: Leffler DA, Dennis M, Edwards George J, Jamma S, Cook EF, Schuppan D, Kelly CP. A validated disease-specific symptom index for adults with celiac disease. Clin Gastroenterol Hepatol. 2009;7:1328-34. PubMed PMID: 19665584. |
Countries
United States
Participant flow
Pre-assignment details
21 patients were enrolled in the study. 1 patient was found to be negative for DQ2 and DQ8, therefore did not have Celiac disease. This patient was excluded from the study. Therefore, for the study we had a total of 20 participants.
Participants by arm
| Arm | Count |
|---|---|
| Low Gluten Group Participants meeting inclusion criteria were randomized into the low gluten group. These participants ate two slices of wheat bread per day (3 g of gluten). Bread was procured from a standard source and gluten dose tested using the RIDASCREEN Gliadin R5 antibody ELISA. The study included a 14-day run-in period followed by a 14 day gluten challenge and a final visit 14 days post-gluten challenge. Other than the dispensed bread, subjects were instructed to remain on their gluten-free diet throughout the duration of the study.
Gluten: 3g | 10 |
| High Gluten Group Participants meeting inclusion criteria were randomized into the low gluten group. These participants ate five slices of wheat bread per day (10 g of gluten). Bread was procured from a standard source and gluten dose tested using the RIDASCREEN Gliadin R5 antibody ELISA. The study included a 14-day run-in period followed by a 14 day gluten challenge and a final visit 14 days post-gluten challenge. Other than the dispensed bread, subjects were instructed to remain on their gluten-free diet throughout the duration of the study.
Gluten: 10g | 10 |
| Total | 20 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Completed Endoscopies | Patient did not complete third endoscopy due to discomfort | 0 | 1 |
Baseline characteristics
| Characteristic | Total | High Gluten Group | Low Gluten Group |
|---|---|---|---|
| Age at Celiac Diagnosis | 35.7 years STANDARD_DEVIATION 14.4 | 31.0 years STANDARD_DEVIATION 11.7 | 45.4 years STANDARD_DEVIATION 13.9 |
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 20 Participants | 10 Participants | 10 Participants |
| Age, Continuous | 43.3 years STANDARD_DEVIATION 13.7 | 38.8 years STANDARD_DEVIATION 13.1 | 48.8 years STANDARD_DEVIATION 13 |
| Baseline Celiac Dietary Adherence test (CDAT) | 11.37 scores on a scale STANDARD_DEVIATION 2.9 | 11.40 scores on a scale STANDARD_DEVIATION 2.9 | 11.33 scores on a scale STANDARD_DEVIATION 3.2 |
| Baseline Celiac Symptom Index (CSI) | 25.26 scores on a scale STANDARD_DEVIATION 5.9 | 22.50 scores on a scale STANDARD_DEVIATION 4.99 | 28.50 scores on a scale STANDARD_DEVIATION 5.78 |
| Baseline Deamidated gliadin peptide (DGP) | 10.90 units STANDARD_DEVIATION 19.6 | 14.04 units STANDARD_DEVIATION 26.49 | 6.70 units STANDARD_DEVIATION 2.59 |
| Baseline Gastrointestinal Symptom Rating Scale (GSRS) | 20.32 scores on a scale STANDARD_DEVIATION 5.1 | 19.20 scores on a scale STANDARD_DEVIATION 3.26 | 22.88 scores on a scale STANDARD_DEVIATION 9.58 |
| Baseline Quality of Life Visual Analog Scale (VAS) | 82.20 scores on a scale STANDARD_DEVIATION 12.5 | 84.40 scores on a scale STANDARD_DEVIATION 12.1 | 80.00 scores on a scale STANDARD_DEVIATION 13.1 |
| Baseline tissue transglutaminase (tTG) | 11.00 units STANDARD_DEVIATION 7.5 | 8.27 units STANDARD_DEVIATION 5.7 | 13.76 units STANDARD_DEVIATION 8.3 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 20 Participants | 10 Participants | 10 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Laboratory Characteristics HLA A1 * 05 alone | 2 Participants | 0 Participants | 2 Participants |
| Laboratory Characteristics HLA DQ2 | 10 Participants | 6 Participants | 4 Participants |
| Laboratory Characteristics HLA DQ2 + DQ 8 | 2 Participants | 1 Participants | 1 Participants |
| Laboratory Characteristics HLA DQ8 | 6 Participants | 3 Participants | 3 Participants |
| Mean number of Intraepithelial lymphocytes | 32.59 unitless STANDARD_DEVIATION 15.1 | 28.4 unitless STANDARD_DEVIATION 13.3 | 37.10 unitless STANDARD_DEVIATION 13.66 |
| Months since Celiac Disease diagnosis | 62.3 months STANDARD_DEVIATION 87.1 | 92.5 months STANDARD_DEVIATION 49.1 | 42.3 months STANDARD_DEVIATION 21.3 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 19 Participants | 10 Participants | 9 Participants |
| Region of Enrollment United States | 20 participants | 10 participants | 10 participants |
| Sex: Female, Male Female | 19 Participants | 9 Participants | 10 Participants |
| Sex: Female, Male Male | 1 Participants | 1 Participants | 0 Participants |
| Villous height to crypt depth ratio | 2.21 unitless STANDARD_DEVIATION 0.8 | 4.33 unitless STANDARD_DEVIATION 6.69 | 2.05 unitless STANDARD_DEVIATION 0.8 |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 10 | 0 / 10 |
| other Total, other adverse events | 1 / 10 | 0 / 10 |
| serious Total, serious adverse events | 0 / 10 | 0 / 10 |
Outcome results
Primary
Crypt Depth to Villous Height Ratio
Histological evaluation of duodenal biopsy samples to evaluate crypt depth to villous height ratio. On the best oriented section of each biopsy fragment, villous height to crypt depth (Vh:Cd) ratio was determined by measuring the mean height /mean depth of adjacent villi/proliferative crypt zones at magnification 100x. Evaluations were considered discrepant Vh:Cd differed by more than 0.5. Overall, there was excellent concordance with the evaluations of the 165 biopsy fragments determined to be optimal for evaluation. The Vh:Cd ratios on individual biopsies from a single averaged to produce a representative Vh:Cd ratio for each endoscopy. Normal Vh:Cd ratio was regarded as 3:1 or greater. Adelman DC, Murray J, Wu TT, Mäki M, Green PH, Kelly CP. Measuring Change In Small Intestinal Histology In Patients With Celiac Disease. Am J Gastroenterol. 2018 Mar;113(3):339-347. doi: 10.1038/ajg.2017.480. Epub 2018 Feb 20. Review. PubMed PMID: 29460921.
Time frame: Screening (Day -7 to -14), Day 3, Day 14
Population: Subjects with biopsy proven celiac disease in remission were enrolled. For Day 3, 17 subjects had evaluable pathology biopsies. On Day 14, 19 participants had evaluable pathology biopsies.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Crypt Depth to Villous Height Ratio | 2.05 ratio | Standard Deviation 0.8 |
| Baseline (Day -14) High Gluten Group | Crypt Depth to Villous Height Ratio | 4.33 ratio | Standard Deviation 6.69 |
| Day 3 Low Gluten Group | Crypt Depth to Villous Height Ratio | 1.19 ratio | Standard Deviation 0.67 |
| Day 3 High Gluten Group | Crypt Depth to Villous Height Ratio | 2.02 ratio | Standard Deviation 0.99 |
| Day 14 Low Gluten Group | Crypt Depth to Villous Height Ratio | 0.98 ratio | Standard Deviation 0.85 |
| Day 14 High Gluten Group | Crypt Depth to Villous Height Ratio | 1.26 ratio | Standard Deviation 1.08 |
p-value: 0.67t-test, 2 sided
Secondary
Assessment of Protein Expression in Intestinal Biopsies
Proportion of participants responding to a gluten challenge. Tissue transglutaminase (tTG) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30. Deamidated gliadin peptide (DGP) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG.
Time frame: Screening (Day -7 to -14), Day 3, Day 14
Population: All 20 subjects were included for the tTG and DGP analysis. For Day 28 High Gluten Challenge Dose Group, 1 participant had both a tTG and DGP \>20 which is why the count is greater than the number analyzed.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 3 Participants |
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 5 Participants |
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 2 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 2 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 4 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 6 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 4 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 5 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 9 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 10 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 5 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 6 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 6 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 14 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 8 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | DGP > 20 | 9 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 or DGP > 20 | 17 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies | tTG > 20 | 8 Participants |
Secondary
Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores
Proportion of participants responding to a gluten challenge. Tissue transglutaminase (tTG) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30. Deamidated gliadin peptide (DGP) scoring: NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG.
Time frame: Screening (Day -7 to -14), Day 3, Day 14
Population: Only 19 subjects were evaluated for Marsh scores because one patient had a single endoscopy which did not produce evaluable samples.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 7 Participants |
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 5 Participants |
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 10 Participants |
| Baseline (Day -14) Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 8 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 8 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 9 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 9 Participants |
| Baseline (Day -14) High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 9 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 5 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 0 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 9 Participants |
| Day 3 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 4 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 0 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 6 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 5 Participants |
| Day 3 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 9 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 19 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 5 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 13 Participants |
| Day 14 Low Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 11 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or tTG >20 | 16 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 | 17 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III | 8 Participants |
| Day 14 High Gluten Group | Assessment of Protein Expression in Intestinal Biopsies Using Marsh Scores | Marsh III or DGP > 20 or tTG > 20 | 19 Participants |
Secondary
Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples
On the best oriented section of each biopsy fragment , the number of intraepithelial lymphocytes (IEL count) per 100 enterocytes was recorded at magnification 400x. IEL counts were considered discrepant if a difference of \>10 IELs existed between counts. Overall, there was excellent concordance with the evaluations of the 165 biopsy fragments determined to be optimal for evaluation. The IEL counts on individual biopsies from a single endoscopy were averaged to produce a representative IEL count for each endoscopy. Adelman DC, Murray J, Wu TT, Mäki M, Green PH, Kelly CP. Measuring Change In Small Intestinal Histology In Patients With Celiac Disease. Am J Gastroenterol. 2018 Mar;113(3):339-347. doi: 10.1038/ajg.2017.480. Epub 2018 Feb 20. Review. PubMed PMID: 29460921.
Time frame: Screening (Day -7 to -14), Day 3, Day 14
Population: Subjects with biopsy proven celiac disease in remission were enrolled. For Day 3, 17 subjects had evaluable pathology biopsies. On Day 14, 19 participants had evaluable pathology biopsies.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 37.08 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 13.66 |
| Baseline (Day -14) High Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 28.91 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 15.81 |
| Day 3 Low Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 44.89 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 20.49 |
| Day 3 High Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 30.68 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 18.09 |
| Day 14 Low Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 47.95 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 14.3 |
| Day 14 High Gluten Group | Count of Intraepithelial Lymphocytes Per 100 Enterocytes in Duodenal Biopsy Samples | 52.36 Count of Lymphocytes Per 100 Enterocytes | Standard Deviation 28.52 |
p-value: 0.409t-test, 2 sided
Secondary
Measures of Immune Activation
IgA anti-human tissue transglutaminase assay (Inova Diagnostics, Inc., San Diego, USA): negative \<20, borderline 20-30, positive \>30. IgA/IgG anti- DGP assay : NEGATIVE \<20, BORDERLINE 20-30, POSITIVE \>30 METHOD IS INOVA ANTI-DEAMIDATED GLIADIN PEPTIDE IGA/IGG.
Time frame: Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28
Population: Subjects with biopsy proven celiac disease in remission were enrolled.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Measures of Immune Activation | IgA anti-tTG | 6.70 units on a scale | Standard Deviation 2.6 |
| Baseline (Day -14) Low Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 6.70 units on a scale | Standard Deviation 2.6 |
| Baseline (Day -14) High Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 14.04 units on a scale | Standard Deviation 26.49 |
| Baseline (Day -14) High Gluten Group | Measures of Immune Activation | IgA anti-tTG | 10.34 units on a scale | Standard Deviation 5.75 |
| Day 3 Low Gluten Group | Measures of Immune Activation | IgA anti-tTG | 13.76 units on a scale | Standard Deviation 10.88 |
| Day 3 Low Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 7.83 units on a scale | Standard Deviation 2.54 |
| Day 3 High Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 14.69 units on a scale | Standard Deviation 27.01 |
| Day 3 High Gluten Group | Measures of Immune Activation | IgA anti-tTG | 11.50 units on a scale | Standard Deviation 6.63 |
| Day 14 Low Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 12.95 units on a scale | Standard Deviation 8.26 |
| Day 14 Low Gluten Group | Measures of Immune Activation | IgA anti-tTG | 11.84 units on a scale | Standard Deviation 9.5 |
| Day 14 High Gluten Group | Measures of Immune Activation | IgA/IgG anti- DGP | 14.04 units on a scale | Standard Deviation 26.49 |
| Day 14 High Gluten Group | Measures of Immune Activation | IgA anti-tTG | 10.34 units on a scale | Standard Deviation 5.75 |
| Day 7 Low Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 13.77 units on a scale | Standard Deviation 10.9 |
| Day 7 Low Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 7.83 units on a scale | Standard Deviation 2.54 |
| Day 7 High Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 14.69 units on a scale | Standard Deviation 27.01 |
| Day 7 High Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 11.50 units on a scale | Standard Deviation 6.63 |
| Day 14 Low Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 17.81 units on a scale | Standard Deviation 22.97 |
| Day 14 Low Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 12.63 units on a scale | Standard Deviation 8.73 |
| Day 14 High Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 15.16 units on a scale | Standard Deviation 10.3 |
| Day 14 High Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 22.74 units on a scale | Standard Deviation 29.31 |
| Day 28 Low Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 37.81 units on a scale | Standard Deviation 45.07 |
| Day 28 Low Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 45.42 units on a scale | Standard Deviation 62.56 |
| Day 28 High Gluten Dose Group | Measures of Immune Activation | IgA/IgG anti- DGP | 41.95 units on a scale | Standard Deviation 33.91 |
| Day 28 High Gluten Dose Group | Measures of Immune Activation | IgA anti-tTG | 43.20 units on a scale | Standard Deviation 53.77 |
Comparison: P Value for IgA anti-tTGp-value: 0.01ANOVA
Comparison: P Value for IgA/IgG anti-DGPp-value: 0.036ANOVA
Comparison: P Value for IgA anti-tTGp-value: 0.013ANOVA
Comparison: P Value for IgA/IgG anti-DGPp-value: 0.006ANOVA
Secondary
Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio)
LAMA evaluation has been reported to be an accurate measure of small intestinal mucosal permeability though assessment of differential absorption of lactulose and mannitol. For LAMA testing, a solution containing 7.5 g lactulose and 2 g mannitol in 100 mL of water was ingested by the participants in the evening after visit 1 and in the evening before each other study visit. The participants were asked to fast for at least 4 h and to void completely before drinking the sugar solution, then fast overnight and collect all overnight and morning urine. Urine sample analyzed for lactulose and mannitol using standardized methodology by liquid chromatography-tandem mass spectrometry.
Time frame: Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28
Population: Subjects with biopsy proven celiac disease in remission were enrolled. Measures of intestinal permeability (urinary lactulose to mannitol ratio) (LAMA) . Four participants were unable to tolerate LAMA testing due to gastrointestinal symptoms.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.23 ratio | Standard Deviation 0.17 |
| Baseline (Day -14) High Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.24 ratio | Standard Deviation 0.25 |
| Day 3 Low Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.65 ratio | Standard Deviation 1.15 |
| Day 3 High Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.17 ratio | Standard Deviation 0.15 |
| Day 14 Low Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.25 ratio | Standard Deviation 0.15 |
| Day 14 High Gluten Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.44 ratio | Standard Deviation 0.6 |
| Day 7 Low Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.45 ratio | Standard Deviation 0.71 |
| Day 7 High Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.29 ratio | Standard Deviation 0.28 |
| Day 14 Low Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.89 ratio | Standard Deviation 1.53 |
| Day 14 High Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.59 ratio | Standard Deviation 0.52 |
| Day 28 Low Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.29 ratio | Standard Deviation 0.24 |
| Day 28 High Gluten Dose Group | Measures of Intestinal Permeability (Urinary Lactulose to Mannitol Ratio) | 0.57 ratio | Standard Deviation 0.82 |
p-value: 0.387t-test, 2 sided
p-value: 0.208t-test, 2 sided
Secondary
Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire
CSI (Celiac Symptom Index) scores range from 7-80. Higher scores indicate greater degree of symptoms CSI: Leffler DA, Dennis M, Edwards George J, Jamma S, Cook EF, Schuppan D, Kelly CP. A validated disease-specific symptom index for adults with celiac disease. Clin Gastroenterol Hepatol. 2009;7:1328-34. PubMed PMID: 19665584.
Time frame: Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28
Population: Subjects with biopsy proven celiac disease in remission were enrolled. On Day -14, one subject in the high gluten dose group missed the CSI. On Day 7 one subject in the high gluten dose group missed the CSI. On Day 14 one subject in the high gluten dose group missed the CSI. On Day 28, one subject in the high gluten dose group and one subject in the low gluten dose missed the CSI.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 28.5 score on a scale | Standard Deviation 5.78 |
| Baseline (Day -14) High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 22.5 score on a scale | Standard Deviation 4.99 |
| Day 3 Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 28.44 score on a scale | Standard Deviation 6.44 |
| Day 3 High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 23.00 score on a scale | Standard Deviation 5.29 |
| Day 14 Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 30.33 score on a scale | Standard Deviation 7.81 |
| Day 14 High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 27.54 score on a scale | Standard Deviation 10.27 |
| Day 7 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 31.11 score on a scale | Standard Deviation 7.9 |
| Day 7 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 28.80 score on a scale | Standard Deviation 13.36 |
| Day 14 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 31.38 score on a scale | Standard Deviation 11.4 |
| Day 14 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 31.00 score on a scale | Standard Deviation 12.7 |
| Day 28 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 26.88 score on a scale | Standard Deviation 7.7 |
| Day 28 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Celiac Symptom Index Questionnaire | 23.90 score on a scale | Standard Deviation 6.74 |
Comparison: P Value for Celiac Symptom Index (CSI) score for Day 3 of Gluten Challengep-value: 0.05t-test, 2 sided
Comparison: P Value for Celiac Symptom Index (CSI) Score from baseline to Day 14p-value: 0.02t-test, 2 sided
Comparison: P Value for Celiac Symptom Index (CSI)score between high gluten group and low gluten group across studyp-value: 0.06ANOVA
Secondary
Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale
Measure Description: GSRS (Gastrointestinal Symptom Rating Scale) scores range 15-105 with higher scores indicating greater degree of symptoms GSRS: Svedlund J, Sjödin I, Dotevall G. GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Dig Dis Sci. 1988;33(2):129-134. doi:10.1007/BF01535722
Time frame: Screening (Day -7 to -14), Day 0, Day 3, Day 7, Day 14, Day 28
Population: Subjects with biopsy proven celiac disease in remission were enrolled. On Day -14, one subject in the high gluten group missed completing the GSRS. On Day 0, two subjects (one in the low gluten group and one subject in the high gluten group) missed completing the GSRS. On Day 7, one subject in the high gluten group missed completing the GSRS. On Day 14, one subject in the high gluten group missed completing the GSRS. On Day 28, one subject in the high gluten group missed completing the GSRS.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Baseline (Day -14) Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 21.63 score on a scale | Standard Deviation 7.05 |
| Baseline (Day -14) High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 19.20 score on a scale | Standard Deviation 3.26 |
| Day 3 Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 22.88 score on a scale | Standard Deviation 9.58 |
| Day 3 High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 18.40 score on a scale | Standard Deviation 3.06 |
| Day 14 Low Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 30.22 score on a scale | Standard Deviation 11.63 |
| Day 14 High Gluten Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 26.45 score on a scale | Standard Deviation 13.18 |
| Day 7 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 28.22 score on a scale | Standard Deviation 9.87 |
| Day 7 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 27.30 score on a scale | Standard Deviation 14.94 |
| Day 14 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 31.00 score on a scale | Standard Deviation 13.71 |
| Day 14 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 31.00 score on a scale | Standard Deviation 17.09 |
| Day 28 Low Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 23.89 score on a scale | Standard Deviation 11.59 |
| Day 28 High Gluten Dose Group | Symptomatic Response to Gluten Exposure Determined by Gastrointestinal Symptom Rating Scale | 19.40 score on a scale | Standard Deviation 4.33 |
Comparison: P Value for the Gastrointestinal Symptom Rating Scale (GSRS) on Day 3 of the Gluten Challengep-value: 0.01t-test, 2 sided
Comparison: P Value for Gastrointestinal Symptom Rating Scale (GSRS) from baseline to Day 14 of Gluten Challengep-value: 0.012t-test, 2 sided
Comparison: P Value for Gastrointestinal Symptom Rating Scale (GSRS) between high gluten group and low gluten group across studyp-value: 0.09ANOVA