How Celiac Disease Is Treated

A gluten-free diet remains one effective treatment

There is no cure for celiac disease and the only treatment known to be effective is a gluten-free diet. Other therapies may be used if a gluten-free diet is unable to provide relief. Although celiac disease can cause deep frustration and anxiety, by working with your doctor and gastroenterologist, you should be more than able to manage your condition and live a full, productive life.

Home Remedies and Lifestyle

At present, a gluten-free diet is the only therapeutic approach able to control celiac disease. By removing the autoimmune trigger, namely gluten, the immune system will have no reason to react abnormally.

Strict adherence to a gluten-free diet can help the intestines heal, resolve chronic symptoms, and reduce the risk to complications such as ulcers, bowel stricture, osteoporosis, and intestinal cancer.

Foods to Avoid

As simple as this may sound, a gluten-free diet can be cumbersome and difficult to maintain, particularly in areas where gluten-free food options are limited. It requires a fundamental change in how you approach eating, even if your current diet is healthy and balanced.

Cereal grains, the primary source of gluten, form a major part of the Western diet. To control celiac disease, you may need to avoid many, if not all, sources of gluten depending on your level of sensitivity to gluten and the stage of your disease. These include:

  • Wheat (including durum, einkorn, and emmer)
  • Wheat germ
  • Rye
  • Barley
  • Bulgur
  • Couscous
  • Farina
  • Graham flour
  • Kamut matzo
  • Semolina
  • Spelt
  • Triticale

On top of that, you would need to avoid ingredients or packaged foods that contain or are derived from the above-listed grains. These may include:

  • Bacon
  • Baked goods
  • Beer
  • Bouillon cubes
  • Bread
  • Breakfast cereals
  • Candies
  • Canned baked beans
  • Cold cuts
  • Egg substitutes
  • French fries (which are often dusted in flour)
  • Gravy
  • Hot dogs
  • Ice cream
  • Instant hot drinks
  • Ketchup
  • Malt flavoring
  • Mayonnaise
  • Meatballs
  • Non-dairy creamer
  • Oats or oat bran (if not certified gluten-free)
  • Pasta
  • Processed cheese
  • Pudding and fruit filling
  • Roasted nuts
  • Salad dressings
  • Sausage
  • Seitan
  • Soups
  • Soy sauce
  • Tabbouleh
  • Veggie burgers
  • Vodka
  • Wheatgrass
  • Wine coolers

In the United States, a product can be labeled "gluten-free" if it contains less than 20 parts per million (ppm) of gluten. While the threshold is usually low enough to avoid symptoms in most people living with the disease, there are some who will react to levels as low as five to 10 ppm.

People with extreme gluten sensitivity may also need to avoid certain non-food products that contain gluten, such as cosmetics, lip balms, shampoos, and non-adhesive stamps and envelopes.

Prescription and over-the-counter medications sometimes use wheat gluten as a binding agent. Talk to your gastroenterologist about the drugs you are taking so that substitutions can be made.

Vitamins and dietary supplements that contain wheat gluten must have "wheat" listed on the label.

Work with a Dietician

The best way to embark on a gluten-free diet is to work with a registered dietitian (RD) who is medically trained and certified in dietetics (as opposed to a nutritionist who may not be). The dietitian can work closely with your doctor to build a dietary strategy based on your medical results and lifestyle.

This is especially important since many Americans get their nutrients and daily fiber from fortified, gluten-containing products like cereal and bread. Working with a dietitian can help identify and prevent nutritional deficiencies that can arise from the loss of dietary gluten.

Because a gluten-free diet can be so challenging, particularly at the start, the dietitian will offer food substitutions to help ease you into the changes. You will also be offered dietary counseling so that you will be better able to:

Foods to Eat

As challenging as all of this may seem, a gluten-free diet is really not all that different from most healthy diets. In addition to avoiding packaged or processed foods, you would fill your plate with naturally wholesome gluten-free foods such as:

  • Eggs
  • Dairy including yogurt, butter, and non-processed cheeses (but check the label of flavored dairy products)
  • Fruits and vegetables including most which are canned or dried
  • Grains including rice, quinoa, corn, millet, tapioca, buckwheat, amaranth, arrowroot, teff, and gluten-free oats
  • Legumes like beans, lentils, peas, peanuts
  • Meat, poultry, and fish (not breaded or battered)
  • Non-gluten starches including potato flour, corn flour, chickpea flour, soy flour, almond meal/flour, coconut flour, and tapioca flour
  • Nuts and seeds
  • Soy foods like tofu, tempeh, and edamame
  • Tamari (a good substitute for soy sauce)
  • Vegetable oils (preferably monounsaturated or polyunsaturated)

Prepared foods certified gluten-free are increasingly available on grocery store shelves, including bread, baked goods, frozen meals, and gluten-free meal kits.

Avoiding Accidental Gluten Exposure

Managing celiac disease involves more than just a change in diet; it requires a change in lifestyle and the support of the people around you. This is not always easy.

Trying to maintain two separate diets in a family can not only be time-consuming but may also expose you to gluten cross-contamination. On the other hand, placing a child without celiac disease on a gluten-free diet can be unhealthy.

It is important, therefore, to achieve "buy-in" from those around you. Even loved ones with the best of intentions may not understand celiac disease and turn off the second you mention the words "gluten-free."

By educating friends and family members, you will able to maintain a gluten-free lifestyle and experience less resistance from those around you.

There are other tips to help avoid gluten exposure at home or in restaurants:

  • Keep gluten-free and gluten-containing foods separate in sealed containers and in separate drawers or cabinets.
  • Clean cooking surfaces and food storage areas.
  • Wash dishes, utensils, and food preparation equipment thoroughly.
  • Avoid wood utensils or cutting boards that can absorb food and potentiate cross-contamination.
  • Speak to your child's teachers and lunch staff if he or she has celiac disease so that accidents can be avoided and special accommodations can be made.
  • Check restaurant menus online before eating out to be sure there are food items you can eat.
  • Call the restaurant in advance to inform them about your health concerns and dietary needs.
  • Book early or late when a restaurant is less busy and better able to accommodate your special requests.

Prescriptions

A gluten-free diet may be all that is needed to control celiac disease symptoms and prevent flares. But, for some people, this may not be enough.

In fact, according to a 2015 study in the journal Digestive Diseases, between 1% and 2% of people with celiac disease will not respond to a gluten-free diet.

The condition, referred to as refractory celiac disease, is rare but serious and can significantly increase the risk of a type of cancer known as T-cell lymphoma. To avoid this, your doctor may prescribe medications that actively suppress the immune system and, with it, the autoimmune response.

Drug treatments are only indicated if you have had villous atrophy and malabsorption symptoms for at least six to 12 months despite strict adherence to a gluten-free diet.

The first-line drug of choice is a class of steroids known as a glucocorticoid. Prednisolone and budesonide are the two oral glucocorticoids mostly commonly prescribed.

While effective at alleviating symptoms, glucocorticoids only appear to reverse intestinal damage in around 33% of patients, according to a 2014 review in Therapeutic Advances in Chronic Diseases. Glucocorticoids can also mask the signs of the intestinal lymphoma.

Other pharmaceutical options include:

In rare cases when T-cell lymphoma is diagnosed, combination chemotherapy would be used. The mainstay of treatment is CHOP therapy (an anagram referring to the drugs cyclophosphamide, doxorubicin, vincristine, and prednisone).

Other promising drugs in the developmental pipeline including larazotide acetate (a potent digestive enzyme that breaks down dietary gluten) and BL-7010 (a high-density polymer that binds to gluten so that it cannot be absorbed).

Surgeries and Specialist-Driven Procedures

In addition to steroids, people with refractory celiac disease may be placed on an elemental diet, a type of liquid diet that is more readily absorbed than solid foods. Total parenteral nutrition (TPN), in which nutrients are delivered through a vein, may be recommended for those with extreme weight loss who are unable to eat.

Surgery

Surgery is not used to treat celiac disease per se but rather to treat complications of the disease, including bowel obstruction, perforation, hemorrhage, and malignancy (cancer).

According to a 2015 study in American Surgery, which evaluated the medical records of 512 adults with celiac disease for 22 years, no less than 11% underwent abdominal surgery as a direct result of the disease.

In people with T-cell lymphoma, surgery may be used in advance of chemotherapy to prevent the perforation of vulnerable tissues.

Autologous stem cell transplants—in which stems cells are harvested from your body prior to chemotherapy and returned to you afterward—have been used successfully to treat intestinal lymphoma in people with refractory celiac disease.

Complementary Alternative Medicine (CAM)

By most accounts, a gluten-free diet is considered the most "natural" approach to celiac disease possible. With that being said, complementary and alternative practitioners believe that there are other ways to control the symptoms of celiac disease and/or better tolerate a gluten-free diet.

Peppermint Oil

Peppermint oil has antispasmodic effects that may help ease intestinal cramping and spasms. Research from the University of South Alabama reported that a sustained-release peppermint oil capsule was twice as effective in alleviating irritable bowel syndrome (IBS) than a placebo. Whether the same would occur with celiac disease has yet to be confirmed.

Peppermint oil taken directly by mouth may cause heartburn and stomach upset. Enteric-coated peppermint capsules are less likely to cause harm. Excessive doses of peppermint oil can be toxic.

Slippery Elm Powder

Slippery elm powder is derived from the bark of the slippery elm. Some people believe that it can protect the intestines by creating a mucus-like coating as it is digested.

A 2010 study in the Journal of Alternative and Complementary Medicine reported that slippery elm powder as able to ease symptoms of constipation-dominant irritable bowel syndrome (IBS-C).

The same effect may be useful in treating constipation that commonly occurs with a gluten-free diet. There is no evidence thus far that slippery elm powder can treat symptoms of celiac disease itself.

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Article Sources

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  2. Woodward J. The management of refractory coeliac disease. Ther Adv Chronic Dis. 2013 Mar;4(2):77–90. doi:10.1177/2040622312473174.

  3. Thompson J, Thompson D, Meyer A. Surgical aspects of celiac disease. Am Surg. 2015 Feb;81(2):157-60.

  4. Cash B, Epstein M, Shah S. A Novel Delivery System of Peppermint Oil Is an Effective Therapy for Irritable Bowel Syndrome Symptoms. Dig Dis Sci. 2016;61:560-71. doi:10.1007/s10620-015-3858-7.

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