Other autoimmune disorders

The link between early diagnosis of coeliac disease and risk of other autoimmune disease

It has been suggested that the chance of developing other autoimmune diseases is increased when diagnosis of coeliac disease is delayed. This may be explained by prolonged exposure to glutenA protein that is found in the cereals wheat, barley and rye. (2). However, one study did not support this (3). Another large multi-centre study also found no connection to support the hypothesis particularly with regards thyroid disease (4).

Thyroid disease

The link between coeliac disease and autoimmune thyroid disease is well established. The NICENational Institute for Health and Clinical Excellence - an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NICE had produced a clinical guideline on the recognition and assessment of coeliac disease. guideline on the recognition and diagnosis of coeliac disease says the prevalence of autoimmune thyroid disease in people with coeliac disease is up to 7% (5).

The prevalence of coeliac disease in patients with autoimmune thyroid disease has been shown to be 4-15 times greater than in the general population. One study found that in a group of patients with coeliac disease 26.2% had autoimmune thyroid disease, compared to 10% of control subjects (6).

Graves’ disease and Hashimoto’s disease                                                                                                                                       

Graves' disease is the most common form of hyperthyroidism. Around 30% of subjects with Graves' disease have a member of the immediate family who also has an autoimmune condition. One study of 111 patients with Grave’s disease found that 4.5% of the participants also had coeliac disease (7).

Hashimoto's thyroiditis is an autoimmune disease where the body's T-cells attack the cells of the thyroid. Patients with Hashimoto's disease have also been shown to be at increased risk of having coeliac disease (8).

It is recommended that certain groups of patients at high risk are screened for thyroid disease, for example, following thyroid surgery and patients taking long term lithium (9). However, this is not currently recommended for patients with coeliac disease.

Liver disease

Abnormal liver biochemistry is common in untreated coeliac disease (10). This suggests that routine investigations for liver disease should be included as part of follow up in coeliac disease (11).

Liver function tests could be carried out alongside tests for anti-endomysial antibodiesExist in the blood and are used by the immune system to attack viruses or bacteria. or tissue-transglutaminase antibodies (tTGA) (11). It must also be considered that false positive tTGA results can occur in coeliac disease.

Autoimmune hepatitis

Autoimmune hepatitis (AIH) is a disorder where the liver is targeted by the body's own autoimmune system. Prevalence of coeliac disease in people with autoimmune hepatitis has been found to be 6.4% (12).

The NICE guideline on recognition and diagnosis of coeliac disease recommends that people with autoimmune liver conditions should be considered for screening of coeliac disease (5). 

Primary biliary cirrhosis

Primary biliary cirrhosis is an autoimmune disease that affects the biliary epithelial cells of the small bile ducts in the liver. Research has shown that there may be at least a threefold increase in the risk of primary biliary cirrhosis in people with coeliac disease (13).

Treatment with a gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. diet in patients with both coeliac disease and liver disease can lead to prevention of hepatic failure even in severe cases where liver transplantation is being considered (14). 

Addison's disease

Addison's disease is an endocrine condition in which the adrenal gland does not produce enough steroid hormones. Lifelong, continuous treatment with steroid replacement therapy is required. People with Addison’s disease can have vague gastrointestinal symptoms.

The incidence of Addison’s disease in people with coeliac disease is between 7 and 12% (15,16). There is a similar immunogenetic background to coeliac disease and Addison's disease, with both diseases being associated with the DR3-DQ2 allele. 

There are various causes of Addison's disease, but autoimmune adrenalitis now accounts for around 70% of all cases. Addison’s disease affects more women than men. As Addison's disease is an autoimmune condition, nearly 50% of those with the condition will develop another autoimmune disorder.

The NICE guideline recommends that people with Addison’s disease should be considered for screening for coeliac disease (5).

Other autoimmune diseases

There are other autoimmune diseases that have been shown to have an increased incidence in people with coeliac disease.

The prevalence of coeliac disease amongst patients with Sjogren's syndrome has been found to be between 4.5% and 15% (17,18).

Evidence suggests that there is a moderately increased prevalence of coeliac disease in patients with sarcoidosis of approximately 4% (19).

References

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2 Ventura A, Magazzu G, Greco L, et al (1999) Duration of exposure to gluten and risk for autoimmune disorders in patients with celiac disease. Gastroenterology. 117: 297-303

3 Sategna Guidetti C, Solerio E, Scaglione N, et al (2001) Duration of gluten exposure in adult coeliac disease does not correlate with the risk for autoimmune disorders. Gut. 49: 502-505.

4 Sategna Guidetti C, Volta U, Ciacci C, et al (2001) Prevalence of thyroid disorders in untreated adult coeliac disease patients and the effect of gluten withdrawal: an Italian multicentre study. American Journal of Gastroenterology. 96: 751-7

5. NICE (2009) Coeliac Disease: Recognition and assessment of coeliac disease. www.nice.org.uk

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14 Kaukinen K, Halme L, Collin P, et al (2002) Celiac disease in patients with severe liver disease: gluten-free diet may reverse hepatic failure. Gastroenterology. 122(4): 88-8.

15 Myhre AG, Aarsetoy H, Undlien DE, et al (2003) High frequency of coeliac disease among patients with autoimmune adrenocortical failure. Scandinavian Journal of Gastroenterology 38(5): 511-5.

16 O'Leary C, Walsh CH, Wieneke P, et al (2002) Coeliac disease and autoimmune Addison's disease: a clinical pitfall. Q J Med. 95: 79-82.

17 Szodoray P, Barta Z, Lakos G, et al (2004) Coeliac disease in Sjogren's syndrome - a study of 111 Hungarian patients. Rheumatology International. 24(5): 278-82.

18 Luft LM, Barr SG, Martin LO, et al (2003) Autoantibodies to tissue transglutaminase in Sjogren's syndrome and related rheumatic diseases. Journal of Rheumatology. 30(12): 2613-9.

19 Rutherford RM (2004) Prevalence of coeliac disease in patients with sarcoidosis. European Journal of Gastroenterology and Hepatology. 16(9): 911-5.