"The crackers challenge": A reassuring low-dose gluten challenge in adults on gluten-free diet without proper diagnosis of coeliac disease

Dig Liver Dis. 2024 Sep;56(9):1517-1521. doi: 10.1016/j.dld.2024.03.004. Epub 2024 Mar 23.

Abstract

Background: Gluten-free diet (GFD) is the one therapy in coeliac disease (CeD). Unfortunately, some patients adopt GFD before the diagnostic work-up. The guidelines suggest a 14-day gluten intake > 3 gr to get CeD diagnosis, although many subjects refuse this approach. Other evidence showed that the intake of 50 mg/day of gluten for 3 months could be useful for CeD diagnosis.

Aims: We performed a dietary study, administering a low dose of gluten in form of "crackers" (about 60-120 mg of gluten/day) for 3 months, to get a final diagnosis of CeD in subjects already on GFD.

Methods: We enrolled adult patients with a suspicion of CeD on self-prescribed GFD. All subjects performed the crackers challenge for 3 months. At the end, all patients were analysed for CeD serology and if positive underwent endoscopy/histology. Also, we recorded the grade of satisfaction for the gluten challenge and the onset of adverse events.

Results: We enrolled 120 patients. All patients concluded the challenge without relevant adverse events. Serological positivity was detected in 54 patients (45%). Histology showed atrophy in 87% and Marsh 1-2 grade in 13% of patients. Ninety-nine patients (83%) were satisfied by this challenge.

Conclusions: The "crackers challenge" is a useful and safe diagnostic approach in people on self-administered GFD.

Keywords: Challenge; Coeliac disease; Gliadin; Gluten; Malabsorption.

MeSH terms

  • Adult
  • Aged
  • Celiac Disease* / diagnosis
  • Celiac Disease* / diet therapy
  • Diet, Gluten-Free*
  • Female
  • Glutens* / administration & dosage
  • Glutens* / adverse effects
  • Humans
  • Male
  • Middle Aged
  • Patient Satisfaction
  • Young Adult

Substances

  • Glutens