Alimentary Tract
Quality of life in celiac disease patients: Prospective analysis on the importance of clinical severity at diagnosis and the impact of treatment

https://doi.org/10.1016/j.dld.2008.05.011Get rights and content

Abstract

Background/aims

Celiac disease (CD) patients are affected in their quality of life (QoL). Our objectives were to assess differences in quality of life of patients according to the clinical presentation at diagnosis, and to determine the time–course impact of a gluten-free diet.

Patients/methods

We prospectively evaluated 132 newly diagnosed adult CD patients and 70 healthy controls using self-administered questionnaires: the Short Form-36 health survey, the Gastrointestinal Symptoms Rating Scale; the Beck Depression Inventory both, at diagnosis and at 3-, 6- and 12-months on treatment.

Results

At diagnosis, patients with classical symptoms (n = 97) exhibited a significantly more pronounced alteration of all items of the three questionnaires than atypical/silent cases (n = 35) (p < 0.01 to <0.00001). Silent CD patients had even better baseline scores (p < 0.05 to <0.00001). Treatment produced a substantial and rapid (3-month) improvement of most outcome measures in classical and atypical patients but not in asymptomatic cases. Both subgroups attained comparable final scores with no differences comparing strictly adherents with partially compliant.

Conclusions

Atypical/silent celiac disease patients have a significantly better baseline quality of life than those with classical symptoms. Treatment induces a rapid and significant improvement in symptomatic cases but not in silent patients with all subgroups having similar 1-year scores comparable to healthy controls.

Introduction

Celiac disease (CD) is a chronic inflammatory enteropathy triggered by dietary gluten in susceptible individuals. The disorder is estimated to affect to 1:100 and 1:300 individuals of the general population [1], [2]. The advent of specific CD serology has shown that the disorder is characterised by wide clinical variability [2], [3]. Celiac disease was classically diagnosed in patients presenting chronic diarrhoea, malabsorption and malnutrition (classical CD) [3]. In contrast, screening in the general population and case-finding studies in high-risk groups have clearly shown that an important group of patients may have minimal symptoms or be completely silent [3]. In this screen-detected population, cases with symptoms that are not primarily associated with the GI tract may also be recognised as atypical or subclinical forms of CD.

By definition, a gluten-free diet (GFD) is always associated with a prompt clinical recovery alleviating symptoms, improving clinical and laboratory parameters and, likely, preventing long-term complications [1]. A strong body of evidence supports the beneficial effect of the therapeutic intervention in patients with classical clinical forms of CD [4]. Contrarily, information about how patients with screen-detected (silent or atypical forms) CD may benefit from diagnosis and dietary intervention still remains unknown [5], [6].

In recent years, has increased the interest in knowing how patients perceive the impact of chronic disorders and how the health state is modified by a given therapeutic intervention or disease outcome [7]. Thus, reports on the assessment of health-related quality of life (QoL) have attempted to reflect many of these aspects specially, how a chronic disease subjectively impacts the physical, social and emotional behaviour of patients from their own perspective [8]. In addition, quantitative parameters measuring QoL may permit accurate comparisons of different stages in the clinical course of a given disorder and, could also help in more appropriate decision making. It is well known that factors affecting QoL are either disease-related or disease-independent and can be measured using global, generic or disease-specific instruments [7], [8].

Indeed, CD is a very interesting chronic disorder where assessment of QoL parameters can produce relevant information on the disease impact, and its outcome and would allow implementation of cost-effective strategies [9].

Recent studies have explored QoL perception by CD patients using generic multi-item questionnaires [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34]. However, the available QoL information in patients with CD is still very limited since most studies were conducted with a cross-sectional design not allowing to know the dynamics of the health perception. In fact, only very few studies have explored QoL measures with a longitudinal design [14], [15], [16], [18], [28], [34]. Although enrolling a small number of patients, these studies suggested that the GFD produces a positive effect and that the therapeutic intervention can be shown in both, symptom-detected and screen-detected patients [18], [28]. This background suggests more prospective studies are necessary in order to strengthen the former evidence with a larger number of patients and enrolling patients representing the wide clinical spectrum of the disorder. In order to optimise QoL assessment in CD, an ideal study should employ multi-dimensional instruments since disease specific tools are not yet available.

Our main aim in this study was to determine prospectively the QoL of a consecutive series of patients diagnosed with CD assessed at the time of diagnosis and at different intervals after starting a GFD. We additionally aimed to establish if the time–course perception of outcome measures is related to the degree of adherence to the diet.

Section snippets

Patients

From December 2004 to December 2005, a series of 151 adult consecutive newly diagnosed CD patients (117 female and 34 male) attending the Small Bowel Diseases Clinic of the “Dr. Carlos Bonorino Udaondo” Gastroenterology Hospital was prospectively enrolled in the study. Patients without biopsy-proven CD or already on a GFD at the time of the first visit were not included. We also excluded patients reluctant to be enrolled or those in whom reasons would preclude not assisting programmed visits

Clinical aspects

At diagnosis, patients with classical CD had similar age, a lower but not significant BMI (p = 0.09) and comparable haemoglobin and serum albumin concentrations (pNS) than atypical/silent cases (Table 1). Sensitivity for serological tests was similar in patients with classical CD (ranging from 75% [AGA IgA] to 99% [a-DGP IgA]) compared with atypical/silent cases (from 82% [AGA IgA] to 96% [a-tTG IgA]) and, importantly, all patients had at least one positive test (data not shown). The proportion

Discussion

The subjective perspective of health state by patients with chronic disorders has become an important outcome measurement gaining interest in the past two decades. Thus, current knowledge suggests that the assessment of QoL in CD patients should be considered as valuable and relevant outcome measure as biological parameters. In general, the profuse literature reporting QoL analyses in CD gives limited information about the baseline characteristics of patients at diagnosis and also, on their

Conflict of interest statement

None declared.

Acknowledgements

The authors thank Dr. Christina Surawicz from the University of Washington, Seattle, Washington, USA, for reviewing the manuscript.

Fabio Nachman was funded by a Research Scholarship from the Consejo de Investigación en Salud, Ministerio de Salud, Gobierno de Buenos Aires. Marcela Planzer del Campo is recipient of the 2007 AIGE (Asociación Interamericana de Gastroenterología) Research Scholarship.

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