Cøliaki diagnostikk og behandling hos voksne

Cøliaki diagnostikk og behandling hos voksne Knut E. A. Lundin Professor, utdanningsleder Klinmed Overlege, Gastro undersøkelse, OUS Forsker, KG Jebsen Senter for Cøliakiforskning

Gluten definitions Gluten as in Gluten free food The glue-ish mass after washing of flour The gliadin and glutenin proteins in wheat, hordeins of barley and secalin of rye

Hvete genomet kartlagt Fem ganger så stort som hos mennesket! Syv sett med kromosomer Ingen data tyder på at «gluten» i hveten har endret seg siste tiårene

Wheat genome deciphered, assembled, and ordered. The International Wheat Genome Sequencing Consortium (IWGSC) et al. Science 2018;361:eaar7191 Published by AAAS

Fig. 2 Reference allergen map of bread wheat. Angéla Juhász et al. Sci Adv 2018;4:eaar8602 Published by AAAS

Gluten intoleranse Bred betegnelse på alle reaksjoner på gluten Cøliaki (1-2% av befolkningen) En slimhinnebetennelse i tynntarmen, virker på hele kroppen, alle har genet HLA-DQ2 eller 8, vanligvis også typisk blodprøve (IgA-TG2) Hveteallergi en rask, allergisk reaksjon (sjeldent) Non-coeliac gluten sensitivity (0-6%????) Klinisk ganske likt cøliaki, men uten typisk betennelse og blodprøve Ludvigsson et al, Gut 2012

CD increases in Scandinavia 2000-2002 Children Incidence 16.2/100.000 Beitnes & Størdal et al, 2012 2008-2010 41.7/ 100.000 1980 Adults, screening Prevalence: 10.5/1000 2001 19.9/1000 Lohi, Aliment Pharmacol Ther, 2007 Dydensborg, Acta Pæd 2011 1996 Children, register Prevalence 0.43/1000 Incidence : /100.000 2010 4/1000 6.9/100.000 1994 Adults, screening Prevalence: 5.3/1000 Ivarsson, J Int Med 1999 2006 Myleus, J Pediatr Gastroenterol Nutr. 2009 Children, born 1993, screening epidemic Prevalence: 29/1000

Endret klinisk presentasjon Tre kardinaltegn: Jernmangel «noen med magen» Alltid trett

The Immune reaction in CD Innate IFN-γ Adaptive IL-15 Sollid/Lundin, Mucosal Immunology 2009, modified

Diagnostic challenge Aim: Diagnose CD correctly, echonomically, definite Leading to lifelong treatment Leading to improvement of symptoms In many cases simple But false pos / false neg serology is not infrequent Biopsy sampling / interpretation / cut-off may be problematic

IgA-Transglutaminase (TG2) I: untreated CD II: before challenge III: during challenge IV: after challenge V: disease controls I: Untreated II: Before challenge III: During challenge V: After challenge V: Disease controls Sulkanen et al. Gastroenterology 1998

Our last celiacs patients

Leffler and Schuppan Am J Gastro 2010, See also Anderson et al. BMC Gastroenterol 2013

NORMAL MUCOSA CELIAC DISEASE MUCOSA + gluten - gluten autoantibodies to tissue transglutaminase (TG2)

Where is the cut-off? Marsh 3 & pos serology Marsh 3 & neg serology Marsh 1-2 & pos serology Marsh 1-2 & neg serology Marsh 0 & neg serology = Definite celiac = Probably celiac = Potential celiac = Unlikely celiac = Definite healthy

Diagnose - voksne Tenke cøliaki! Teste mens pas spiser gluten: Serumprøve (IgA-TG2 og IgG-DGP) Falskt positive og falskt negative svar ikke uvanlig Gastroskopi med biopsi fortsatt nødvendig Gråsone svar ikke uvanlig Hvis pasienten allerede lever glutenfritt Blodprøve på HLA-DQ2 og DQ8 Provokasjon med gluten i 4 uker (?) før biopsi

Behandling cøliaki Osteoporose vanlig Gluten fri kost Uten hvete, rug, bygg Havre godkjent Glutenfritt øl (Ringnes Lite etc) Ofte vedvarende problemer minner om IBS Terapi vanskelig Nøyere med dietten Behandling som for IBS? FODMAP? Prosjekt!

Hvorfor behandle cøliaki? Ubehandlet cøliaki sannsynlig assosiert med øket dødelighet (x 1,1-2 - 3?) Glutenfri kost beskytter sannsynlig mot malignitet og død Bedret QoL Osteoporose problem Beskytter neppe mot andre immunsykdommer (diabetes, thyreoidea etc)

Ny test? NRK 20/9-15

HLA-DQ2-gliadin tetramers and diagnosis Modified gluten peptides bound to HLA-DQ2 in antigen presenting cells Tetramer construct for detection of gluten specific T cells T cells recognize HLA-DQ2/DQ8-bound gluten peptides Sollid/Lundin, Mucosal Immunology 2009, modified

A blood test to sort out celiac disease without gluten exposure! Tetramer construct for detection of gluten specific T cells Sarna et al 2018 Gastroenterology

Even more simple test? Vikas K. Sarna1, Gry I. Skodje1, Suyue Wang2, Leslie J. Williams2, John L. Dzuris2, Ludvig M. Sollid1, Knut E.A. Lundin1, Robert P. Anderson2 1K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Norway 2ImmusanT, Inc., Cambridge, MA USA Introduction and Background Median Plasma Cytokines in CeD and NCGS Stored plasma collected by Sarna et al (Gut 2017) from 20 CeD volunteers up to 6 hours after gluten ingestion on the first day of a 14-day gluten challenge were assessed. Detailed clinical, genetic and immunological data were available including gastrointestinal symptoms, HLA-DQ genotype, and the baseline frequency of gluten-specific effector memory CD4+ T cells in blood measured by flow cytometry using HLA-DQ2.5 and DQ8 gluten tetramers. C ed v e rs u s N C G S IL - 2 IL - 8 F o ld C h a n g e (M e d i a n ) 12 IL - 1 0 12 *** 10 12 10 8 10 8 6 8 6 4 *** 2 6 4 4 ** * 2 0 2 0 2 4 Stored plasma collected by Skodje et al (manuscript submitted) from 57 volunteers conforming to a diagnosis of NCGS according to Sapone et al (BMC Medicine 2012) collected up to 6 hours after gluten ingestion on the first day of a 7-day double-blind, placebo-controlled crossover gluten challenge were also assessed. Gluten challenge utilized muesli bars identical to those used by Sarna et al (Gut 2017). Detailed clinical, and genetic data were available including gastrointestinal symptoms, and HLA-DQ genotype. 0 6 2 4 H o u rs 6 2 4 H o u rs 6 H o u rs C e D S ig n if ic a n c e C o m p a r e d t o B a s e lin e * p < 0.0 5, * * p < 0.0 1, * * p < 0.0 0 1 N o S ig n if ic a n t N C G S F o ld C h a n g e s O b s e r v e d Gluten Induced Cytokine Change Over 6 Hours Concentrations of IL-2, IL-8 and IL-10 were measured by MSD V-plex electrochemiluminescence assays in thawed plasma from blood collected before, and at 2, 4, and 6 hours after ingestion of meusli bars containing 5.7 g gluten. CeD vs NCGS Plasma Cytokine 2 to 6 Hours after Gluten Study 2. NCGS Subjects on Gluten Free Diet Study 1. CeD Subjects on Gluten Free Diet Frequency of gluten-specific T cells determined by HLA-DQ:gluten tetramers in Flow Cytometry Based on current knowledge, gluten-induced elevation in plasma I L-2 as a marker of T cell activation would differentiate between CeD and NCGS, but gluten-induced elevation in plasma I L-8 and possibly I L-10 as markers of innate immune activation would be associated with both CeD and NCGS Consume muesli bar containing 5.7 g gluten Gastrointestinal symptoms recorded by the Gastrointestinal Symptom Rating Scale (GSRS-IBS) or Visual Analogue Scale (VAS) Objective ROC : Area Under the Curve (AUC) Blood plasma collected prior to gluten challenge, and then 2, 4 and 6 hours after challenge To evaluate IL-2, IL-8 and IL-10 in plasma after gluten ingestion in CeD and NCGS subjects on GFD using highly sensitive assays. Blood plasma IL-2, -8, and -10 were measured by MSD V-Plex electrochemiluminescence assays R O C c u r v e : A U C S u m o f F o ld C h a n g e 2, 4, a n d 6 h o u r s 100 Conclusions S e n s itiv it y % 80 Patients with CeD on GFD elevate plasma I L-2 as well as I L-8 and I L-10 within 6 hours after gluten ingestion Patients with NCGS on GFD do not elevate plasma I L-2 or I L-8 or I L-10 after gluten ingestion 60 IL -2 40 IL -8 20 I L-2 is elevated in CeD patients from two hours and peaks at four hours, which is earlier than I L-8 and I L-10. IL -1 0 0 0 I L-2 elevations from 2 to 6 hours after gluten are correlated with the baseline frequency of gluten-specific CD4+ T cells in 20 40 60 80 100 1 0 0 % - S p e c if ic it y % HLA-DQ2.5+ CeD. I L-2 assessment after gluten ingestion has the potential to differentiate between CeD and NCGS IL-2 and Tetramer Staining Plasma Cytokines Fold Change from Baseline and Acute Symptoms IL-8 6 hr IL-10 IL-2 IL-8 NCGS-60 DQ8/X 2.0 2.9 1.7 NCGS-44 DQX/X 2.9 1.5 NCGS-15 DQX/X 2.2 1.3 2.9 NCGS-18 DQ8/X 1.9 2.5 1.3 NCGS-52 NCGS-61 2.0 1.3 1.4 NCGS-34 DQX/X 2.1 1.4 NCGS-02 1.8 1.7 DQX/X 1.9 0.4 0.3 NCGS-07 NCGS-17 NCGS-48 1.3 1.8 1.4 DQ8/X 1.9 1.3 DQX/X 1.3 1.8 NCGS-35 2.1 NCGS-04 1.3 1.4 1.3 NCGS-26 1.5 NCGS-59 DQ8/X 1.5 1.3 NCGS-01 0.4 0.4 0.3 NCGS-12 NCGS-24 NCGS-37 NCGS-06 DQ8/X 1.3 DQX/X DQX/X 0.4 0.5 DQX/X NCGS-09 DQ8/X NCGS-11 NCGS-13 DQX/X 1.5 1.3 1.4 NCGS-20 DQX/X NCGS-21 DQ8/X 1.5 1.9 NCGS-23 1.7 1.4 2.5 NCGS-33 1.8 NCGS-39 DQX/X 1.3 NCGS-40 0.3 0.3 0.3 NCGS-41 0.0 0.1 0.2 DQX/X DQX/X 0.5 0.5 NCGS-47 DQX/X NCGS-53 1.6 1.5 1.5 1.5 NCGS-16 DQX/X 0.3 NCGS-29 NCGS-50 DQX/X 1.3 DQX/X DQX/X 1.3 1.3 1.3 NCGS-49 NCGS-27 NCGS-08 DQX/X NCGS-14 DQ8/X NCGS-28 DQX/X 0.5 1.5 0.5 NCGS-43 DQX/X 1.3 0.5 NCGS-22 DQX/X 2 hr IL-2 IL-8 IL-10 800 IL-2 CD1343 DQ8/DQ2.2 10.1 1.5 AUC of I L-2 vs Tetramer Baseline in CeD 4 hr Symptom (VAS) 6 hr IL-8 IL-10 IL-2 IL-8 IL-10 2 hr 4 hr 330.5 4.5 1.3 60 13.1 1.3 CD442 DQ2.5/DQ2.5 1.4 344.4 15.6 19.2 136.9 16.3 4 75.0 88.0 80 CD1300 15.5 76.0 3.2 128.4 3.0 1.5 8.0 10.0 2 60 400 CD1295 18.3 2.9 49.9 27.4 3.6 24.4 7.1 2.0 15.0 12.0 50 200 CD1302 DQ8/8 28.6 6.6 21.4 3.5 1.4 CD1353 0.5 22.5 1.5 1 1.8 50 CD1340 DQ2.5/DQ2.5 1.7 16.8 1.9 4.7 15.7 2.3 3.1 6.0 19.0 Subject 600 500 100 9.0 6 hr 100 4.0 26.0 10.0 0.0 33.0 18.0 9.0 10.0 25 0.0 >20 25.0 15 9.0 40 30 20 CD1303 10.0 8.0 2.4 1.3 0.0 0.0 15 CD1378 1.7 11.4 4.9 3.5 2.4 1.6 22.0 33.0 >10 CD1351 11.3 3.5 1.4 4.1 1.5 1.3 3.0 7.0 3.0 10 8 CD1178 DQ2.5/DQ8 3.6 3.6 1.6 3.6 6 CD1296 1.5 4.7 2.4 2.9 2.1 1.6 1.6 4 CD1339 DQ2.5/DQ2.2 3.2 1.6 1.9 1.4 HLAgenotype 600 CD1300 295.8 12.1 CD1343 DQ8/DQ2.2 1272 6.9 500 CD1295 142.5 49.5 CD1302 DQ8/8 79.65 3.0 400 CD1353 56.76 1 CD1294 DQ8/DQ7 5.79 0.1 200 100 CD1303 CD1340 2.2 DQ2.5/DQ2.5 58 29.04 5.6 50 CD1378 28.06 23.5 20 CD1351 27.81 2.4 15 CD1178 DQ2.5/DQ8 14.35 3.1 10 CD1296 12.49 1.4 8 CD1339 6.0 8.0 20.0 8 8.0 1 8.0 6 0.0 2.0 6.0 4 2 CD1298 5.78 1.4 1 1 CD1284 4.02 5.2 8.0 0 0 CD1366 4 2 CD1342 0.3 2.4 0.3 1.8 0.3 6.0 2.0 1 CD1299 3.7 1.6 0.3 1.7 2.0 3.0 0.5 CD1294 DQ8/DQ7 1.5 1.7 1.5 1.4 10.0 7.0 2 0.2 CD1298 1.6 1.3 2.4 0.0 0.0 0.1 CD1284 0.0 0.0 0.0 0 CD1366 3.0 3.0 4.0 CeD DQ2.5 negative 46.8 DQ2.5/DQ2.5 827.1 CD442 HLAgenotype Subject CeD DQ2.5 positive 800 3.3 DQ2.5/DQ2.2 9.35 6 CD1342 7.49 1.6 4 CD1299 6.54 5.0 NCGS-42 NCGS-46 NCGS-56 HLAgenotype Subject IL-10 AUC IL-2 IL-2 H L A -D Q 2.5 0.0 + C e D S u b je c ts 1000 Summary of Plasma Cytokines: Fold change of IL-2>IL-8> IL-10 Fold change of IL-2, IL-8 and IL-10 in CeD >>> NCGS groups -Fold change starting time IL-2>IL-8>IL-10 IL-2 increase correlates with IL-8 and IL-10 increase but is more sensitive. R s q u a re d = 0.4 9 5 1 P v a lu e = 0.0 0 2 4 100 10 NCGS-66 DQX/X NCGS-19 NCGS-30 DQX/X 0.5 Tetramer Baseline B. Celiac on GFD 4 hr IL-10 AUC IL-2 IL-8 A U C o f IL -2 2 hr IL-2 VAS symptom scores HLAgenotype Tetramer Baseline A. NCGS on GFD Subject NCGS-63 What about a signal in blood after a gluten containing snack? Method / Study Design Using various biomarkers often including IL-8, in vitro activation of innate immune cells incubated with gluten peptides, gliadin digests, and by amylase-trypsin inhibitors has been interpreted as supporting direct effects of gluten on innate immunity and as an explanation for early symptoms after gluten ingestion in CeD and in NCGS (Ciccocioppo & Corrazza. Clin Exp Immunol 2005; Lammers et al., Immunology 2010; Junker et al., J Exp Med 2012) We recently reported the effects of consuming one muesli bar containing 5.7 g gluten daily for two weeks in a cohort of 20 CeD volunteers on GFD (Sarna et al., Gut 2017). Plasma collected before, and at 2, 4, and 6 hours after gluten ingestion on the first day was assessed with a 27plex cytokine assay. Significantly elevated levels of IL-8, IP-10 and eotaxin were found at 6 hours. Peak median fold changes from pre-gluten were 1.6, 1.6 and 1.4 respectively. Plasma IL-2 and IL-10 were below detection levels. Recently, we reported that a highly sensitive electro-chemiluminescence assay reveals substantial increases in low but quantifiable plasma levels of IL-2, IL-8, and IL-10 two to six hours after bolus gluten ingestion in volunteers on GFD if they have CeD but not in non-ced controls (TyeDin JA et al., Gastroenterology 2017; 152: S114.) IL-2 is a cytokine preferentially secreted by activated T cells. IL-8 and IL10 are secreted by T cells, but are non-specific markers of immune activation. AUC of IL-2 fold change over 2, 4, and 6 hrs Dependent on on-site analysis Expensive & difficult Can only be done in dedicated labs Increase in Plasma Interleukin(IL)-2, IL-8, and IL-10 from 2 to 6 Hours on Oral Gluten Challenge Differentiates Between Celiac Disease (CeD) and Non-Celiac Gluten Sensitivity (NCGS) in Patients on Gluten-Free Diet (GFD) Fold change over 2, 4, and 6 hrs Flow cytometry based test is 1 0.1 1 H L A - D Q : g lu te n te tr a m e r + 10 7 + T 100 EM /1 0 6 C D 4 + c e lls S u m o f IL - 2 fo ld c h a n g e a t 2, 4, a n d 6 h r ( n = 1 6 ) ( A re a U n d e r th e C u r v e [A U C ])

I L - 2 F o l d C h a n g e M e d i a n I L - 8 a n d I L - 1 0 F o l d C h a n g e M e d i a n 4-hour test distinguishes CD and NCGS! 1 2 1 0 8 6 3 x * p < 0. 0 0 1 2 x * p < 0. 0 1 1 x * p < 0. 0 5 * * * * * * C e D I L - 2 C e D I L - 8 C e D I L - 1 0 N C G S I L - 2 N C G S I L - 8 2. 0 1. 5 4 N C G S I L - 1 0 2 * * * 1. 0 0 2 4 6 8 H o u r s 2 hr 4 hr 6 hr 2 hr 4 hr 6 hr 2 hr 4 hr 6 hr Median for CeD 10.0 3.6 1.5 1.8 1.3 IQR (25-75) (0-2.65) IL-2 IL-8 IL-10 (5-8) (5-25) (2.02-25.58) (3-3.98) (6-1.58) (1.75-18.56) (7-2.71) Median for NCGS (6-1.54) IQR (25-75) (7-0) (1-6) (8-9) (6-1) (8-5) (9-2) (6-8) (4-1) (0-2)

sciencemag.org, May 23rd 2018

Forskjellige syn NCGS skyldes en spesifikk reaksjon mot proteiner i gluten NCGS skyldes en reaksjon mot vanskelig fordøyelige karbohydrater (FODMAP)

Oppsummering Cøliaki vanlig (1-2 % av befolkningen) Diagnose hos voksne basert på Klinisk mistanke Blodprøve (IgA-TG2 og IgG-DGP) Gastroskopi med biopsi Glutensensitivitet uten cøliaki enda vanligere Usikker diagnose Ikke biomarkører eller skopifunn

Problems with biopsy Quality of biopsy interpretation is not perfect Ludvigsson et al 2009 BMC Gastroenterol -but can be improved, incl IgA deposits Koskinen et al 2010 J Clin Gastroenterol Taavela et al 2013 PLoS One Adelman et al 2018 Am J Gastroenterology Is not quality control a critical part of any pathologist s practive?

GFD som trend Australia 20 million innbyggere 1 million eller mer på GFD Markedsvekst 15-20 %/år New Zealand 5 % av barn gluten-fri USA 6 % av befolkningen? USD 5-10 000 000 000 Markedsvekst > 20 % Non-coeliacs på GFD holder dietten strengt Men ikke alltid kontroll på symptomer

Pressure from celebrities Djokovic Lady Gaga Kim Kardashian

Menneskeheten utryddes ila 1 generasjon?

Prøvd gluten fri mat eller diett i 2013? Percentage Alle 17 % Kvinner 21 % Menn 14 % 15-24 år 32 % 25-45 år 17 % 46 + år 14 % Kilde: Statens Forbruksundersøkelser

Large intestine Small intestine FODMAPs water delivery Luminal distension gas production Diarrhoea, pain, bloating, distension, wind

Coeliac disease in 10% of HLA- DQ2 + patients on a gluten-free diet Non-coeliac gluten sensitive (NCGS) in paper III-IV

Morphology/ tetramer examples Morphology Tetramer staining Patient 1 Patient 2 Patient 3 positive

Mucosal cytokine response after short-term gluten challenge in celiac disease and nonceliac gluten sensitivity Margit Brottveit 1*, Ann-Christin R. Beitnes 2*, Stig Tollefsen 2, 3, Jorunn E. Bratlie 4, Frode L. Jahnsen 5, Finn-Eirik Johansen 5, Ludvig M. Sollid 6, Knut E. A. Lundin 2, 7 Submitted for publication 15 CD and 30 HLA-DQ2 + NCGS patients 7 untreated CD and 6 disease controls Duodenal biopsies Quantitative reverse transcriptase (qrt)-pcr for cytokine mrna Immunohistochemistry

Quantitative reverse transcriptase (qrt)- PCR for cytokine mrna

Questionnaires: Symptoms, personality traits, somatisation, health related quality of life, anxiety and depression 22 CD patients, 31 NCGS patients 40 healthy controls without challenge

More symptoms in NCGS than CD 60 GSRS-IBS Abdominal symptoms NCGS CD 30 General SHC symptoms Score 40 20 Score 20 10 0 d0 d3 d6 Challenge 0 d0 d3 d6 Challenge Abdominal symptoms: Gastrointestinal Symptom Rating Scale Irritable Bowel Version (GSRS-IBS) General symptoms. Subjective Health Complaints (SHC)

No signs of somatisation CD NCGS HCs GBB-total score* SCL-90-R som* 59.4 (51.3) 74.6 (52.8) 20.1 (17.7) 0.5 () (0.5) 0.2 (0.2) Mean scores (SD). *Comparison of scores: NCGS = CD > HCs GBB (Giessener Physical Complaints Checklist) >150~ somatisation Symptom Checklist-90-Revised (SCL-90-R) somatisation subscale, > ~ somatisation

Oslo work on NCGS PhD Margit Brottveit Celiac disease rare among NCGS individuals from general population 130 responders, 35 were DQ2+, 3 with CD Gastroscopy and HLA-DQ2:gliadin peptide tetramer test Brottveit et al Am J Gastro 2011 No signs of psychosomatic disorder Three days challenge with bread Brottveit et al Scand J Gastro 2012 NCGS intestines with signs of immune activation Increased levels of IEL, activation of IFN-g after bread challenge Brottveit et al Am J Gastro 2013

Symptoms after intake of bread Skodje et al 2016 Scand J Gastroenterol

Challenge the placebo problem Supply all food? Traditional placebo Capsules flour or placebo Research tool Lundin and Alaedini 2012 Catassi et al 2016 Quinoa based müsli bars with and without clean gluten and FODMAP Pic of gluten bar

Dagsrevyen 17/11-2017

UCD Untreated celiac disease TCD Treated celiac disease