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Introductory Chapter: Celiac Disease - Now and Then

Written By

Jianyuan Chai

Submitted: 04 March 2021 Published: 12 May 2021

DOI: 10.5772/intechopen.97238

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Celiac Disease

Edited by Jianyuan Chai

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1. Introduction

Celiac disease, in one sentence, can probably be defined as a complex autoimmune disorder triggered by gluten ingestion in people carrying the HLA-DQ2 or HLA-DQ8 gene. The most common symptom associated with the disease is diarrhea after eating gluten-containing food, such as wheat, rye, or barley products. The earliest documentation about the celiac disease can be traced back to the 2nd century AD and it was written by a Greek physician named Aretaeus the Cappadocian [1]. He used the Greek word “koiliakos” or “coeliacs” to call it, meaning abdomen discomfort. He said in English translation: “If the stomach be irretentive of food and if it passes through undigested and crude, and nothing ascends into the body, we call such persons coeliacs”. He also identified the connection between the illness and eating bread and learned that fasting was helpful to reduce the symptoms. This knowledge was elaborated 1700 years later by a British doctor, Samuel Jones Gee, in his lecture entitled “On the Celiac Affection” [2]. He revealed the fact that celiac disease could affect not only children but also adults, but mostly children under 5 years old. If the patient must eat bread, he suggested, “Bread cut thin and well toasted on both sides … But if the patient can be cured at all, it must be by means of diet”. This is consistent with our knowledge today. A more interesting description about the celiac disease was found in the three lectures given by Professor George F. Still at the Royal College of Physicians of London [3], who vividly pictured his observation of the sick children: “What appears to be an infant little more than 12 months old … it is at least a year or two older, perhaps three or four years older, than its appearance would suggest”. Now we know that this is due to malnutrition associated with such eating disorders. Another important discovery was made by Dicke, a Dutch pediatrician, who noticed that celiac disease almost vanished in the Netherlands during World War II when bread was on a serious scarcity, but it came back quickly when the Swedish airplanes dropped bread to the region. Later, he figured out that it was gluten that made people sick [4]. Starting from the mid-20th century, people have been developing various endoscopic tools to reach into the duodenum or even further down into the small intestine to obtain tissue samples for pathological analysis. This technology significantly accelerated our understanding of the pathogenesis of the celiac disease [5]. Later on, gluten antibodies were discovered in patients with celiac disease and their diagnostic value was soon recognized in the medical community [6]. This work built the foundation for serological detection of celiac disease today. From the 70s, people started to look for the possible genetic reasons for celiac disease, and soon a connection with HLA-DQ2 and HLA-DQ8 expression was found [7, 8]. After the 90s, our current concept of celiac disease was gradually formed: this is an autoimmune disorder that can be triggered by gluten ingestion in people with a DQ2 or DQ8 genetic background.

Looking back the history, our understanding of celiac disease has experienced such path: presentations of the disease (ancient time till 19th century) – identification of gluten as the cause (mid-20th century) – pathology of the disease (the 50-the 60s) – immunology of the disease (the 60–70s) – genetics of the disease (the 70–80s) – current concept of the disease (after the 90s).


2. Pathogenesis of celiac disease

Gluten is a common name for the viscoelastic proteins present in various grains, such as gliadin from wheat, hordein from barley, and secaline from rye. The main amino acids of these proteins are glutamine and proline (or collectively called prolamine), which makes them resistant to proteolytic enzymes of the human gut. Using gliadin as an example, gliadin contains 35% glutamine and 15% proline and can only be broken down to oligopeptides of 20–50 amino acids in the human intestine. For the majority of people, these peptides remain in the lumen of the intestine and eventually are expelled out from the body, but for those individuals who carry HLA-DQ2/DQ8 genes, they can bind to the chemokine receptor CXCR3 on the intestinal epithelial cells to induce zonulin overexpression. Zonulin in structure is similar to the zona occludens toxin from Vibrio cholera and has the function to disassemble the tight junctions between epithelial cells via protease activated receptor 2/EGFR pathway. This allows the half-digested gluten peptides to pass through the mucosal barrier and reach the lamina propria [9]. Gluten peptides can also reach the lamina propria through the epithelial cells using IgA/CD71 channels. Once getting into the lamina propria, these peptides are deamidated by tissue transglutaminase 2 (tTG2), converting glutamine to glutamate, which makes them easier to be taken up by HLA-DQ2 and –DQ8 bearing antigen-presenting cells. This triggers the generation of gluten-specific CD4+ T lymphocytes [10]. Upon gluten stimulation, these gluten-specific T cells start to produce a lot of pro-inflammatory cytokines, including interleukin (IL)-15, IL-21, and interferon-γ. IL-15 stimulates CD8+ T cells to migrate to the epithelial layer to attack the epithelial cells, causing villous atrophy, a hallmark of celiac disease [11]. Gluten-specific T cells also promote the activation of B cells, which develop into plasma cells, producing the autoantibodies against tTG2, which is used nowadays as the biomarker in serological tests for celiac disease [12].

Although all of the celiac disease patients are either DQ2 or DQ8 positive, only 1–3% of the people with such genetic background develop the disease [13, 14], indicating that other factors must be involved. Microbial infection in the duodenum has been postulated to play a role. For instance, Pseudomonas aeruginosa, a bacteria that is commonly found in the duodenum of celiac disease patients, produces elastases that can degrade the gluten into highly immunogenic peptides [15]. Other factors that have been investigated for their possible contributions to the onset of celiac disease include (1) time and amount of gluten consumption in infants [16, 17, 18], (2) virus infection [19, 20], (3) H. pylori eradication [21, 22], (4) maternal gluten consumption [23], (5) maternal C-section [24, 25, 26], (6) maternal iron deficiency [27, 28], (7) summer birth [29, 30, 31], (8) maternal high education [32], (9) maternal non-smoking [33], (10) high socio-economic status [34, 35], (11) geographic locations [36, 37, 38], (12) Vitamin D deficiency [39], (13) antibiotic use in childhood [40], and (14) PPI use [41]. However, none of these factors are sufficient to solve the puzzle completely. It seems that each one of these factors plays a part but they (at least some of them) must work together to trigger the intestinal allergy to gluten and the subsequent clinical manifestations of celiac disease.

While many years of effort has been made, the pathogenesis of celiac disease still remains as a mystery today.


3. Current therapeutic strategies for celiac disease

Since celiac disease is troubling at least 1% of the world population, people have been actively searching for therapeutic solutions to control the disease. The effort has been focusing on each key component in the entire pathogenic process, which can be classified into the following five categories.

3.1 Reduction of gluten immunogenicity

The simplest way that one can think of to cure celiac disease is to stop eating all gluten-containing food. Without the trigger, the disease of course will never occur. Believe it or not, this is the most effective method thus far to treat celiac disease – a gluten-free diet. However, wheat products have been the main component of our daily meals for thousands of years, not only for the Western world but also for the Orientals. The only difference between the western bread and the eastern bread is that the former is baked and the latter is steamed. Quitting such a lifestyle for most people is hard to do. For this reason, scientists have been trying to engineer wheat genetically so that it will produce flour containing less or not all gluten without losing much of the original gastronomic properties. Unfortunately, this has not been very successful so far [42, 43].

3.2 Prevention of gluten degradation

The idea is to use synthetic polymers or specific antibodies to sequester gluten in the gut so that it would not be degraded into an immunogen. BL-7010 is such a polymer. In vitro analyses as well as animal studies all showed promising results, including no toxicity [44], gluten selectivity [45], and villous protection [46]. Now its clinical trials are underway. Using antibodies to seize gluten in the intestine has also gained encouraging results. AGY is an IgY antibody generated from chicken eggs against gluten. Taking AGY capsules has been shown capable to reduce gliadin absorption from 42.8% to 0.7% in an animal study [47]. A clinical trial with AGY also obtained effectiveness [48].

3.3 Prevention of gluten peptides entering intestinal mucosa

The next target is intestinal epithelial integrity. The majority of gluten peptides get to the lamina propria through para-cellular space, which is sealed by tight junctions in healthy individuals. Overexpression of zonulin triggered by gluten stimulation in DQ2/DQ8 carriers causes a collapse of the tight junctions. Therefore, if mucosal permeability is restricted, gluten peptides will largely remain in the intestinal lumen. Larazotide acetate is an octa-peptide developed against zonulin. Phase I and II clinical trials all showed substantial improvement in clinical symptoms, although some patients had some minor side-effect, such as headache and urinary infections [49, 50, 51, 52].

3.4 Inhibition of tissue transglutaminase

As mentioned above, the immunogenicity of gluten peptides in celiac disease patients is largely dependent on their deamidation by tTG-2. Therefore, inhibition of tTG-2 activity would reduce the amount of immunogen production. Because tTG-2 activation also contributes to several other diseases, such as Parkinson’s, Alzheimer’s, Huntington’s, and even some cancers, a great effort has been put in to develop tTG-2 inhibitors. An animal study has shown some encouraging results using this strategy in the treatment of celiac disease. A phase II clinical trial has been initiated.

3.5 Prevention of immune reaction

Celiac disease is an autoimmune disorder. The therapeutic strategies discussed above all intend to stop gluten from becoming an immunogen. The last approach is targeting the immune reaction assuming the four strategies above all failed. This includes using chemical blockers to mask the active sites of DQ2, using immunodominant gluten peptides to vaccinate DQ2/DQ8 carriers, transplanting special bacteria that are capable to produce nontoxic gluten in the human gut, using steroids, etc. Many such products will be out soon.


  1. 1. Adams F. The extant works of Aretaeus the Cappadocian. London: London Sydenham Society. 1856: 350
  2. 2. Gee SJ. On the coeliac affection. St. Bartholomew’s Report. 1888; 24: 17-20
  3. 3. Still CF. The Lumleian Lectures on coeliac disease. Lancet. 1918; ii: 163-6, 193-7, 227-9
  4. 4. Dicke WK, Weijers HA, Van de Kamer JH. Coeliac disease. II. The presence in wheat of a factor having a deleterious effect in cases of coeliac disease. Acta Paediatr. 1953; 42: 34-42
  5. 5. Paveley WF. From Aretaeus to Crosby: a history of coeliac disease. Br Med J. 1988; 297: 1646-1649
  6. 6. Berger E, Buergin-wolff A, Freudenberg E. Diagnostic value of the demonstration of gliadin antibodies in celiac disease. Klin Wochenschr. 1964; 42: 788-790
  7. 7. Falchuk ZM, Rogentine GN, Strober W. Predominance of histocompatibility antigen HL-A8 in patients with gluten-sensitive enteropathy. J Clin Invest. 1972; 51: 1602-1605
  8. 8. Solhein BG, Ek J, Thune PO, Baklien K, Bratlie A, Rankin B, Thoresen AB, Thorsby E. HLA antigens in dermatitis herpetiformis and celiac disease. Tissue Antigens. 1976; 7: 57-59
  9. 9. Schumann M, Siegmund B, Schulzke JD, Fromm M. Celiac disease: Role of the Epithelial Barrier. Cell. Mol. Gastroenterol. Hepatol. 2017; 3: 150-162
  10. 10. Ting YT, Dahal-Koirala S, Kim HSK, Qiao SW, Neumann RS, Lundin KEA, Petersen J, Reid HH, Sollid LM, Rossjohn J. A molecular basis for the T cell response in HLA-DQ2.2 mediated celiac disease. Proc. Natl. Acad. Sci. USA. 2020; 117: 3063-3073
  11. 11. Jabri B, Sollid LM. T Cells in Celiac Disease. J. Immunol. 2017; 198: 3005-3014
  12. 12. Høydahl LS, Richter L, Frick R, Snir O, Gunnarsen KS, Landsverk OJB, Iversen R, Jeliazkov JR, Gray JJ, Bergseng E, Foss S, Qiao SW, Lundin KEA, Jahnsen J, Jahnsen FL, Sandlie I, Sollid LM, Løset GÅ. Plasma Cells Are the Most Abundant Gluten Peptide MHC-expressing Cells in Inflamed Intestinal Tissues From Patients With Celiac Disease. Gastroenterology. 2019; 156: 1428-1439.e10
  13. 13. Sollid LM, Markussen G, Ek J, Gjerde H, Vartdal F, Thorsby E. Evidence for a primary association of celiac disease to a particular HLA-DQ alpha/beta heterodimer. J Exp Med. 1989; 169: 345-350
  14. 14. Yuan J, Zhou C, Gao J, Li J, Yu F, Lu J, Li X, Wang X, Tong P, Wu Z, Yang A, Yao Y, Nadif S, Shu H, Jiang X, Wu Y, Gilissen L, Chen H. Prevalence of celiac disease autoimmunity among adolescents and young adults in China. Clin Gastroenterol Hepatol. 2017; 15:1572-1579 e1
  15. 15. Comino I, Real A, de Lorenzo L, Cornell H, López-Casado MÁ, Barro F, Lorite P, Torres MI, Cebolla A, Sousa C. Diversity in oat potential immunogenicity: basis for the selection of oat varieties with no toxicity in coeliac disease. Gut. 2011; 60:915-922
  16. 16. Lionetti E, Castellaneta S, Francavilla R, Pulvirenti A, Tonutti E, Amarri S, Barbato M, Barbera C, Barera G, Bellantoni A, Castellano E, Guariso G, Limongelli MG, Pellegrino S, Polloni C, Ughi C, Zuin G, Fasano A, Catassi C; SIGENP (Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition) Working Group on Weaning and CD Risk. Introduction of gluten, HLA status, and the risk of celiac disease in children. N Engl J Med. 2014; 371:1295-1303
  17. 17. Vriezinga SL, Auricchio R, Bravi E, Castillejo G, Chmielewska A, Crespo Escobar P, Kolaček S, Koletzko S, Korponay-Szabo IR, Mummert E, Polanco I, Putter H, Ribes-Koninckx C, Shamir R, Szajewska H, Werkstetter K, Greco L, Gyimesi J, Hartman C, Hogen Esch C, Hopman E, Ivarsson A, Koltai T, Koning F, Martinez-Ojinaga E, te Marvelde C, Pavic A, Romanos J, Stoopman E, Villanacci V, Wijmenga C, Troncone R, Mearin ML. Randomized feeding intervention in infants at high risk for celiac disease. N Engl J Med. 2014; 371:1304-15
  18. 18. Andrén Aronsson C, Lee HS, Koletzko S, Uusitalo U, Yang J, Virtanen SM, Liu E, Lernmark Å, Norris JM, Agardh D; TEDDY Study Group. Effects of gluten intake on risk of celiac disease: a case-control study on a swedish birth cohort. Clin Gastroenterol Hepatol. 2016; 14:403-409 e3
  19. 19. Stene LC, Honeyman MC, Hoffenberg EJ, Haas JE, Sokol RJ, Emery L, Taki I, Norris JM, Erlich HA, Eisenbarth GS, Rewers M. Rotavirus infection frequency and risk of celiac disease autoimmunity in early childhood: a longitudinal study. Am J Gastroenterol. 2006; 101:2333-2340
  20. 20. Bouziat R, Hinterleitner R, Brown JJ, Stencel-Baerenwald JE, Ikizler M, Mayassi T, Meisel M, Kim SM, Discepolo V, Pruijssers AJ, Ernest JD, Iskarpatyoti JA, Costes LM, Lawrence I, Palanski BA, Varma M, Zurenski MA, Khomandiak S, McAllister N, Aravamudhan P, Boehme KW, Hu F, Samsom JN, Reinecker HC, Kupfer SS, Guandalini S, Semrad CE, Abadie V, Khosla C, Barreiro LB, Xavier RJ, Ng A, Dermody TS, Jabri B. Reovirus infection triggers inflammatory responses to dietary antigens and development of celiac disease. Science 2017; 356:44-50
  21. 21. Dore MP, Salis R, Loria MF, Villanacci V, Bassotti G, Pes GM. Helicobacter pylori infection and occurrence of celiac disease in subjects HLADQ2/DQ8 positive: a prospective study. Helicobacter 2018; 23:e12465
  22. 22. Konturek PC, Karczewska E, DieterichW, Hahn EG, Schuppan D. Increased prevalence of Helicobacter pylori infection in patients with celiac disease. Am J Gastroenterol. 2000; 95:3682-3683
  23. 23. Uusitalo U, Lee HS, Aronsson CA, Yang J, Virtanen SM, Norris J, Agardh D; Environmental Determinants of the Diabetes in the Young (TEDDY) study group. Gluten consumption during late pregnancy and risk of celiac disease in the offspring: the TEDDY birth cohort. Am J Clin Nutr. 2015; 102:1216-1221
  24. 24. Emilsson L, Magnus MC, Stordal K. Perinatal risk factors for development of celiac disease in children, based on the prospective Norwegian Mother and Child Cohort Study. Clin Gastroenterol Hepatol. 2015; 13:921-927
  25. 25. Koletzko S, Lee HS, Beyerlein A, Aronsson CA, Hummel M, Liu E, Simell V, Kurppa K, Lernmark Å, Hagopian W, Rewers M, She JX, Simell O, Toppari J, Ziegler AG, Krischer J, Agardh D; TEDDY Study Group. Cesarean section on the risk of celiac disease in the offspring: the teddy study. J Pediatr Gastroenterol Nutri. 2018; 66:417-424
  26. 26. Dydensborg Sander S, Hansen AV, Stordal K A. -Andersen MN, Murray JA, Husby S. Mode of delivery is not associated with celiac disease. Clin Epidemiol. 2018; 10:323-332
  27. 27. Stordal K, Haugen M, Brantsaeter AL, Lundin KE, Stene LC. Association between maternal iron supplementation during pregnancy and risk of celiac disease in children. Clin Gastroenterol Hepatol. 2014; 12:624-31 e1-2
  28. 28. Yang J, Tamura RN, Aronsson CA, Uusitalo UM, Lernmark Å, Rewers M, Hagopian WA, She JX, Toppari J, Ziegler AG, Akolkar B, Krischer JP, Norris JM, Virtanen SM, Agardh D; Environmental Determinants of Diabetes in The Young study group. Maternal use of dietary supplements during pregnancy is not associated with coeliac disease in the offspring: the environmental determinants of diabetes in the young (TEDDY) study. Br J Nutr. 2017; 117:466-72
  29. 29. Lebwohl B, Green PH, Murray JA, Ludvigsson JF. Season of birth in a nationwide cohort of coeliac disease patients. Arch Dis Child. 2013; 98:48-51
  30. 30. Assa A, Waisbourd-Zinman O, Daher S, Shamir R. Birth month as a risk factor for the diagnosis of celiac disease later in life: a population-based study. J Pediatr Gastroenterol Nutr. 2018; 67:367-370
  31. 31. Ivarsson A, Hernell O, NystromL, Persson LA. Children born in the summer have increased risk for coeliac disease. J Epidemiol Community Health 2003; 57:36-39
  32. 32. Canova C, Zabeo V, Pitter G, Romor P, Baldovin T, Zanotti R, Simonato L. Association of maternal education, early infections, and antibiotic use with celiac disease: a population-based birth cohort study in northeastern Italy. Am J Epidemiol. 2014; 180: 76-85
  33. 33. Wijarnpreecha K, Lou S, Panjawatanan P, Cheungpasitporn W, Pungpapong S, Lukens FJ, Ungprasert P. Cigarette smoking and risk of celiac disease: a systematic review and meta-analysis. United European Gastroenterol J. 2018; 6: 1285-1293
  34. 34. Kondrashova A, Mustalahti K, Kaukinen K, Viskari H, Volodicheva V, Haapala AM, Ilonen J, Knip M, Mäki M, Hyöty H; Epivir Study Group. Lower economic status and inferior hygienic environment may protect against celiac disease. Ann Med. 2008; 40:223-231
  35. 35. Roy A, Mehra S, Kelly CP, Tariq S, Pallav K, Dennis M, Peer A, Lebwohl B, Green PH, Leffler DA. The association between socioeconomic status and the symptoms at diagnosis of celiac disease: a retrospective cohort study. Therap Adv Gastroenterol. 2016; 9:495-502
  36. 36. Unalp-Arida A, Ruhl CE, Choung RS, Brantner TL, Murray JA. Lower prevalence of celiac disease and gluten-related disorders in persons living in Southern vs Northern Latitudes of the United States. Gastroenterology 2017; 152:1922-32.e2
  37. 37. Teresi S, Crapisi M, Vallejo MD, Castellaneta SP, Francavilla R, Iacono G, Ravelli A, Menegazzi P, Louali M, Catassi C. Celiac disease seropositivity in Saharawi children: a followup and family study. J Pediatr Gastroenterol Nutr. 2010; 50:506-509
  38. 38. Lionetti E, Gatti S, Pulvirenti A, Catassi C. Celiac disease from a global perspective. Best Pract Res Clin Gastroenterol. 2015; 29:365-379
  39. 39. Mårild K, Tapia G, Haugen M, Dahl SR, Cohen AS, Lundqvist M, Lie BA, Stene LC, Størdal K. Maternal and neonatal vitamin D status, genotype and childhood celiac disease. PLoS ONE. 2017; 12:e0179080
  40. 40. Kemppainen KM, Vehik K, Lynch KF, Larsson HE, Canepa RJ, Simell V, Koletzko S, Liu E, Simell OG, Toppari J, Ziegler AG, Rewers MJ, Lernmark Å, Hagopian WA, She JX, Akolkar B, Schatz DA, Atkinson MA, Blaser MJ, Krischer JP, Hyöty H, Agardh D, Triplett EW; Environmental Determinants of Diabetes in the Young (TEDDY) Study Group. Association between early-life antibiotic use and the risk of islet or celiac disease autoimmunity. JAMA Pediatr. 2017; 171:1217-1225
  41. 41. Lebwohl B, Spechler SJ, Wang TC, Green PH, Ludvigsson JF. Use of proton pump inhibitors and subsequent risk of celiac disease. Dig Liver Dis. 2014; 46:36-40
  42. 42. Carroccio A, Di Prima L, Noto D, Fayer F, Ambrosiano G, Villanacci V, Lammers K, Lafiandra D, De Ambrogio E, Di Fede G, Iacono G, Pogna N. Searching for wheat plants with low toxicity in celiac disease: between direct toxicity and immunologic activation. Dig Liver Dis. 2011; 43: 34-39
  43. 43. International Wheat Genome Sequencing Consortium (IWGSC), et al. Shifting the limits in wheat research and breeding using a fully annotated reference genome. Science. 2018; 361: eaar7191
  44. 44. Pinier M, Verdu EF, Nasser-Eddine M, David CS, Vézina A, Rivard N, Leroux JC. Polymeric binders suppress gliadin-induced toxicity in the intestinal epithelium. Gastroenterology. 2009; 136:288-298
  45. 45. Pinier M, Fuhrmann G, Galipeau HJ, Rivard N, Murray JA, David CS, Drasarova H, Tuckova L, Leroux JC, Verdu EF. The copolymer P(HEMA-co-SS) binds gluten and reduces immune response in gluten-sensitized mice and human tissues. Gastroenterology. 2012; 142:316-25.e1-12
  46. 46. McCarville JL, Nisemblat Y, Galipeau HJ, Jury J, Tabakman R, Cohen A, Naftali E, Neiman B, Halbfinger E, Murray JA, Anbazhagan AN, Dudeja PK, Varvak A, Leroux JC, Verdu EF. BL-7010 demonstrates specific binding to gliadin and reduces glutenassociated pathology in a chronic mouse model of gliadin sensitivity. PLoS ONE. 2014; 9:e109972
  47. 47. Gujral N, Löbenberg R, Suresh M, Sunwoo H. In-vitro and in-vivo binding activity of chicken egg yolk immunoglobulin Y (IgY) against gliadin in food matrix. J Agric Food Chem. 2012; 60:3166-3172
  48. 48. Sample DA, Sunwoo HH, Huynh HQ, Rylance HL, Robert CL, Xu BW, Kang SH, Gujral N, Dieleman LA. AGY, a novel egg yolk-derived anti-gliadin antibody, is safe for patients with Celiac disease. Dig Dis Sci. 2017; 62:1277-1285
  49. 49. Paterson BM, Lammers KM, ArrietaMC, Fasano A,Meddings JB. The safety, tolerance, pharmacokinetic and pharmacodynamic effects of single doses of AT-1001 in coeliac disease subjects: a proof of concept study. Aliment Pharmacol Ther. 2007; 26:757-766
  50. 50. Leffler DA, Kelly CP, Abdallah HZ, Colatrella AM, Harris LA, Leon F, Arterburn LA, Paterson BM, Lan ZH, Murray JA. A randomized, double-blind study of larazotide acetate to prevent the activation of celiac disease during gluten challenge. Am J Gastroenterol. 2012; 107:1554-1562
  51. 51. Kelly CP, Green PHR, Murray JA, Dimarino A, Colatrella A, Leffler DA, Alexander T, Arsenescu R, Leon F, Jiang JG, Arterburn LA, Paterson BM, Fedorak RN. Larazotide acetate in patients with coeliac disease undergoing a gluten challenge: a randomised placebo-controlled study. Aliment Pharmacol Ther. 2013; 37:252-262
  52. 52. Leffler DA, Kelly CP, Green PHR, Fedorak RN, DiMarino A, Perrow W, Rasmussen H, Wang C, Bercik P, Bachir NM, Murray JA. Larazotide acetate for persistent symptoms of celiac disease despite a gluten-free diet: a randomized controlled trial. Gastroenterology. 2015; 148:1311-9.e6

Written By

Jianyuan Chai

Submitted: 04 March 2021 Published: 12 May 2021