World Digestive Health Day WDHD – May 29, 2016 The exact mechanism of action is unknown but thought to be related to inhibition of neutrophil migration and function. Patients should be monitored for the adverse effects of diamonodiphenyl sulfone, primary hemolytic anaemia, methemoglobinaemia, agranulocytosis, and neuropathy. For patients unable to tolerate dapsone, sulfapyridine may be substituted; however dapsone does not improve GI mucosal pathology. More than 70% of patients on GFD are able to slowly wean off dapsone over a period of 2-3 years.24 More than 90% of our 80-100 DH patients on a strict GFD cannot wean off dapsone in the first years. More than 50% of patients go on for at least 5-10 years. No reports are available on long term follow up of dapsone in DH. FOLLOW UP AND GLUTEN ATAXIA Of the three gluten-induced conditions, gluten ataxia is the only one without a straightforward path to diagnosis.24 In fact, although awareness is growing, it has not been accepted by all mainstream neurologists. If any antibodies to gluten are present in lab tests, then our recommendation is to consider for all ataxia patients “with no alternative cause for their ataxia” to start GFD for 12-24 months. Stabilization or even improvement after 1 – 2 years would be a strong argument that the patients suffer from gluten ataxia.25 We need proper observational studies about this issue. MEDICAL MANAGEMENT IN FOLLOW-UP Follow-up can be arranged in primary care as long as the expertise is available. Unfortunately, the critical number of celiac patients per general physician is insufficient. In the Netherlands, only 25,000 patients are known in a population of 16 million inhabitants. We have around 10,000 GPs. This means that a general GP controls as a mean only 2.5 patients. This suggests that their expertise is insufficient. The number of gastroenterologists in the country is 500, so in general, gastroenterologists should control at least 50 celiac patients per doctor. Prompt access for our celiac patients to specialized centers around the country is recommended but not well-organized. So far only 15-20 gastroenterologists in our country are devoted to CD. However, access to those doctors is limited; the majority of them is each controlling only 150-200 celiac patients per year. Access for patients to a well-trained celiac interested gastroenterologists is limited. Secondary, especially tertiary, care is recommended if complicated CD arises. It should be noted that this care is not well organized, not only in Europe, but worldwide. MANAGING ADULT CELIAC DISEASE IN THE OUTPATIENT CLINIC, continued FOLLOW UP AND BONES Long-term adherence to GFD leads to significant improvement in bone density. However, we see major abnormalities in bone density in our population diagnosed above 50 years of age, females as well as males. All of these high-risk patients for bone fractures should be treated with calcium and vitamin D. All osteopenia/ osteoporotics in these age-groups are treated for 36 months with intravenous bisphosphonates, four times per year 60mg APD. During our yearly follow-up we measure calcium, alkaline phosphatase, vitamin D, and Parathyroid hormone for a compensatory increase of the bone mass. Bone density should be measured in every adult newly diagnosed celiac patient. A 24-months treatment course with risedronate 35mg once weekly, concomitant with calcium and Vitamin D supplementation, in osteopenic inflammatory bowel disease (IBD) patients improved bone density.27 Similar studies are urgently needed in CD. Appropriate criteria for follow-up bone density in daily practice for CD are lacking. We repeat bone density investigation in the case of osteopenia in general after an interval of three years. In general, gastroenterologists pay more attention to post-menopausal women with CD in supplementation of calcium than to males; however, we do have the impression that the lumbar spine quality of males is more severely hampered than in females. HYPOSPLENISM Hyposplenism associated with CD may result from impaired immunity to encapsulate pathogenic microorganisms. Arbitrarily, we vaccinate all celiac patients with a spleen volume below 100cc with Pneumovac®. MICROSCOPIC COLITIS Microscopic colitis (MC), including lymphocytic and collagenous colitis, are associated with autoimmune disorders, especially with CD. In case celiac patients during follow-up develop watery diarrhea, we always screen for MC.28 MC is very common in our celiac center, maybe even too common based on selection bias in our referral celiac patients. We treat them with slow release budesonide (Entocort®) for three months and in the case of a relapse with thiopurines especially tioguanide (thiosix®).29 36 WGO Handbook on DIET AND THE GUT World Digestive Health Day WDHD May 29, 2016
WGO Handbook on Diet and the Gut_2016_Final
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