Coeliac disease enteropathy and symptoms may be aggravated by angiotensin receptor blockers in patients on a gluten‐free diet. Issue 8 (29th June 2021)

• Record Type: Journal Article
• Authors: O'Morain, Neil; Shannon, Eileen; McManus, John; Warner, Vanessa; Leeson, Hilary; O'Donovan, Helen; Egan, Brian; Byrnes, Valerie
• Is Part Of: United European Gastroenterology journal. Volume 9:Issue 8(2021)
• Page Start: 973
• Page End: 979
• Publication Date: 2021-06-29
• Subjects: angiotensin receptor blocker -- anti‐TTG -- ARB‐enteropathy -- coeliac disease -- enteropathy -- gluten‐free diet -- MARSH; Gastroenterology -- Periodicals; Periodicals; 616.33005
• DOI: 10.1002/ueg2.12117
• Languages: English
• ISSNs: 2050-6406

Abstract

Abstract: Background: Angiotensin receptor blocker‐associated enteropathy (ARB‐e) is an increasingly recognised clinical entity with symptoms and histological findings identical to coeliac disease (CD). There is evidence to suggest immune‐mediated mucosal injury in ARB‐e with a high prevalence of DQ2/DQ8; however, as IgA anti‐tissue transglutaminase (anti‐TTG) is usually negative, an insult other than TTG‐mediated injury is suspected. The impact of ARBs on disease activity in patients with CD is not known. Objective: To assess the effect of ARB exposure on patients with established CD. Methods: A patient record search of 1142 individual patients attending a dedicated coeliac clinic from 2010 to the present identified 59 patients treated with ARB. Those with CD confirmed by serology (TTG + ve/EMA + ve) and histopathology (Marsh criteria) were included ( n = 40, 0.52%). Data collected included disease duration, compliance with gluten‐free diet (GFD), reported symptoms (diarrhoea, weight loss and abdominal pain), surrogate markers of absorption (Vitamin D, Iron, Calcium and Haemoglobin), in addition to anti‐TTG titre and histological grade at last follow up. Patients were age and sex‐matched in a 1:2 ratio with CD patients not taking ARBs (controls), with comparable rates of disease duration and compliance with GFD. Results: The ARB and control groups were matched in terms of age (mean 66.2 years) and gender (female 63%). Strict compliance with GFD was reported in 55% and 56%, respectively. Persistent symptoms were reported in 10/40 (25%) of the ARB group compared with 7/82 (9%) of controls ( p = 0.0181). There were lower rates of mucosal healing (Marsh grade 0) in the ARB group (36% n = 11) compared to controls (55%, n = 33). There was no significant difference in anti‐TTG titres. Surrogate markers of absorption were comparable across the groups, except for Vitamin D which was lower in those taking olmesartan ( p = 0.0015). Conclusions: ARBs may aggravate the enteropathy and lead to increased symptoms in patients with bone fide diagnosed CD following a GFD. Key summary: Summarise the estabished knowledge on this subject Angiotensin receptor blocker‐associated enteropathy (ARB‐e) is an increasingly recognised clinical entity with symptoms and histological findings identical to coeliac disease (CD). The exact cause of mucosal injury in ARB‐e is unknown however there is evidence to suggest immune‐mediated mucosal injury in ARB‐e with a high prevalence of DQ2/DQ8, however as anti‐tissue transglutaminase (TTG) is usually negative, an insult other than TTG‐mediated injury is suspected. The impact of ARBs on disease activity in patients with CD is not known. What are the significance and/or new findins of this study? Coeliac patients who take ARBs are more likely to have persistent symptoms and lower rates of mucosal healing than their age‐matched coeliac controls. This observation appears to be independent of TTG mediated injury, akin to that reported in non‐coeliac populations. ARB use in patients with established coeliac disease may confound the interpretation of clinical and histological response to a gluten‐free diet.