Celiac Disease
Loren Bonner
Pharmacists want to help their patients. But when it comes to counseling those who have celiac disease or gluten allergies, there’s probably a lot pharmacists need to know.
Patients with celiac disease or other gluten-related disorders cannot tolerate the proteins found in wheat, barley, and rye. These prolamin proteins and prolamin-like proteins are almost unavoidable, however, because the grains are used as baking, flavoring, thickening, or coloring agents in many manufactured food products. Not only are they ingredients in so many products, but cross-contamination with the grains can occur during processing and storage as well.
According to Carmela Silvestri, PharmD, a New Jersey Certified Consultant Pharmacist and chair of the New Jersey Pharmacists Association Task Force on Gluten in Medications, it’s important for pharmacists to understand the challenges patients with celiac disease face in attempting to completely eliminate gluten. She said pharmacists should be willing to do what they can to make sure their patient’s medications, vitamins, and herbal products do not contain measurable gluten.
How can a pharmacist verify that a product is safe for a patient with celiac disease or other gluten-related disorders?
Because prescription medications and many other drug products are not labeled to indicate they are safe, Silvestri said pharmacists can start by checking the product label for gluten-containing ingredients.
“It is rare for medications to contain a gluten-containing grain in the ingredient list. However, patients who experience pain on exposure can be fearful of any new oral products that must be taken regularly,” she said.
The gold standard, according to Silvestri, is to contact the manufacturer or check their website about the contents of the drugs and to be sure that excipients derived from grains do not introduce cross-contamination.
Pharmacists can also consult www.glutenfreedrugs.com. A pharmacist, Steve Plogsted, created the list of drugs on the site using the answers manufacturers have given in the past.
Silvestri added that it’s important to listen to the patient as well. A change in response to a medication could indicate an absorption issue that requires a dose change. If the patient has a return of celiac symptoms after starting a new prescription, trying a different manufacturer’s product might be warranted.
What is celiac disease?
Upward of 40% of the U.S. population has a genetic predisposition to celiac disease, but active celiac disease shows up in only about 1% of the population. The disease can appear at any point during a person’s lifetime, and the trigger is unknown. Because of the variation of intestinal and extraintestinal symptoms, patients can sometimes wait years to receive a proper diagnosis.
Patients with celiac disease range in the intensity of their reaction to gluten.
“Each patient has their own threshold,” said Silvestri. “Some are really sensitive and others not so much, and some have intestinal damage but don’t show any clinical symptoms at all.”
The most sensitive patients are the ones at risk from cross-contamination with wheat and other grains.
Celiac disease is different from other gluten-related disorders because it’s an inherited autoimmune disorder that affects the small intestine. Nonceliac gluten sensitivity or a gluten intolerance is not the same thing, according to the Celiac Disease Center at University of Chicago Medicine. This condition causes the body to mount a stress response, usually in the form of GI symptoms. A gluten or wheat allergy, much like any allergy, causes the immune system to respond to what it thinks is a foreign substance in the body.
Labeling on food and medication
An FDA hazard study concluded that gluten exposure would need to be below 1 parts per million (ppm) to protect the most sensitive patients from experiencing some celiac-related symptoms. Gluten-free labeling in food products is set below the consistently measurable threshold of 20 ppm and should protect most patients.
“Since trace amounts below the 20 ppm threshold have the potential to cause a response in the most sensitive patients, a strict gluten-free diet consists mostly of fresh protein sources and fruits and vegetables with the addition of certified gluten-free grains—this means limited exposure to processed foods,” said Silvestri.
As for medications, the celiac community has requested that FDA label medications for gluten content. The agency has drafted proposed guidelines, but a final ruling has not yet been announced.