Wheat-free Diet in the Treatment of Sjogren's Syndrome
Recent data show that some foods can increase intestinal mucosa permeability and immune activation of subjects with gastrointestinal (GI) symptoms. Wheat seems the most frequent food which activates this inflammatory response and can cause both GI and extra-intestinal symptoms. Patients suffering from wheat-related troubles, in absence of celiac disease diagnosis, can suffer from non-celiac wheat sensitivity (NCWS) and our previous studies showed that about 25% of them are also affected by autoimmune diseases (AD). A gluten-free diet (GFD) can influence inflammatory pattern of AD, including Sjogren's syndrome (SS). Thus, the investigators would enquire if SS patients may also suffer from NCWS and how a wheat-free diet (WFD) modifies their clinical features, and inflammatory and cytokine pattern. The investigators will also assess how wheat reintroduction, by an open challenge, modifies their clinical parameters, intestinal permeability, and both local and systemic inflammatory response.
Accepts Healthy Volunteers
Healthy volunteers are participants who do not have a disease or condition, or related conditions or symptoms
An interventional clinical study is where participants are assigned to receive one or more interventions (or no intervention) so that researchers can evaluate the effects of the interventions on biomedical or health-related outcomes.
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|Eligible Ages||18 Years - 65 Years|
The study will be a prospective, randomized, placebo-controlled, single center clinical trials. Patients diagnosed with SS, fulfilling the American-European Consensus Group criteria for SS, will be recruited at the outpatient clinic of the Rheumatology Department, University Hospital 'P. Giaccone' of Palermo, Italy. Inclusion criteria of SS patients.
- - age >18 and <65 years; - negativity of anti-deamidated gliadin protein (anti-DGP) immunoglobulins (Ig) class A (IgA) and immunoglobulins (Ig)G, anti-tissue transglutaminase (anti-tTG) class IgA and IgG, and Endomysium antibodies (EmA); - absence of intestinal villous atrophy, documented in all the patients carrying the DQ2 and/or the DQ8 Human Leukocyte Antigen (HLA) haplotypes (thus irrespective of CD-specific serum antibody negativity.
- - absence of WA (negative prick-test and/or specific serum immunoglobulin (Ig) E assay for wheat, gluten, and gliadin).
- - age <18 and >65 years; - self-exclusion of gluten/wheat from the diet and refusal to reintroduce it, for diagnostic purposes, before entering the study; - pregnancy; - alcohol and/or drug abuse; - Helicobacter pylori and other bacterial and/or parasitic infections; - diagnosis of chronic inflammatory bowel disease and other organic pathology affecting the digestive system (e.g., severe liver disease), nervous system diseases, major psychiatric disorders, immunological deficits, and impairments that limit physical activity; - diagnosis of cancer.
- - patients undergoing chemotherapy and/or radiotherapy.
- - salivary flux study, by standard sialometry, and salivary samples collection (treated to block enzymatic digestion of proteins), to dose immunologic and inflammatory markers; - a blood sample, for the analysis of inflammatory markers, cytokine profile, and intestinal permeability markers; - a urine collection, after the administration of the lactulose/mannitol (LA/MA) test, to define intestinal permeability; - a collection of stools, for calprotectin assay and definition of the gut microbiota; - a dietary consult to better explain the dietary approach and provide any information useful to allow adherence to the elimination diet; - finally, an alimentary (for the self-assessment of adherence to the diet) and symptom's diary will be provided to all patients, which must be filled-in daily.
This trial id was obtained from ClinicalTrials.gov, a service of the U.S. National Institutes of Health, providing information on publicly and privately supported clinical studies of human participants with locations in all 50 States and in 196 countries.
Phase 1: Studies that emphasize safety and how the drug is metabolized and excreted in humans.
Phase 2: Studies that gather preliminary data on effectiveness (whether the drug works in people who have a certain disease or condition) and additional safety data.
Phase 3: Studies that gather more information about safety and effectiveness by studying different populations and different dosages and by using the drug in combination with other drugs.
Phase 4: Studies occurring after FDA has approved a drug for marketing, efficacy, or optimal use.
The sponsor is the organization or person who oversees the clinical study and is responsible for analyzing the study data.
|University of Palermo|
The person who is responsible for the scientific and technical direction of the entire clinical study.
|Antonio Carroccio, MDGiuliana Guggino, MD|
|Principal Investigator Affiliation||University of PalermoUniversity of Palermo|
Category of organization(s) involved as sponsor (and collaborator) supporting the trial.
|Overall Status||Not yet recruiting|
The disease, disorder, syndrome, illness, or injury that is being studied.
|Sjogren's Syndrome, Non-celiac Gluten Sensitivity|
In recent years, the existence of a wheat-related disorder, in patients who do not suffer from celiac disease (CD) or wheat allergy (WA), has been definitively ascertained and defined as non-celiac wheat sensitivity (NCWS). Its prevalence in the general population is unknown but self-reported NCWS is around 10%. Conflicting data have been reported about the underlying physiopathology. It has been known for years how exposure to gliadin, both in CD and in healthy patients (albeit with reduced levels in the latter), is able to alter intestinal permeability acting on zonulin release and signalling mechanisms. More recently, it has been shown that wheat has high concentrations of wheat amylase-trypsin inhibitors (ATIs), proteins able to activate innate immunity via toll-like receptor-4 (TLR-4) on myeloid cells. Orally ingested ATIs increase intestinal inflammation by activating gut and mesenteric lymphnode myeloid cells. An increasing number of data have shown that patients with NCWS could have an association with autoimmune diseases, including thyroiditis, undifferentiated connective tissue disease, psoriatic arthritis, spondylarthritis, and Sjogren's syndrome (SS). SS is an autoimmune disease characterized by an infiltrate of mononuclear cells, mainly lymphocytes, in the exocrine glands, especially the salivary and lacrimal glands. Some preliminary data suggested that a GFD can reduce sialadenitis and increase salivary flow in SS and CD patients. Furthermore, some SS patients have an inflammatory response (release of nitric oxide) to a rectal gluten challenge. Based on these evidences, as well as on the ability of gluten/wheat to increase intestinal permeability, altering zonulin mechanisms of regulation and signalling, and the ability of some of its components (ATIs, but not only) to activate a local inflammatory response, it could be hypothesized that gluten/wheat may represents one of the pathogenetic environmental factors of SS and that its intake may be able to worsen symptoms in affected patients. In our hypothesis, exposure to gluten/wheat would cause a release of zonulin, which, binding to the surface of the intestinal epithelial cells, is able to modify cell cytoskeleton and to cause the loss of normal occludins function, ultimately leading to an increased monolayer permeability. This increase in permeability would result in greater exposure of the immune system cells to gluten/wheat molecules via activation of TLR-4, with an increase in the infiltration and activation of myeloid cells in the intestinal mucosa and an augmented activity of lymphnode dendritic cells. Such local inflammatory response would have systemic repercussions with alteration of normal cytokine pattern and infiltration of monocytes/macrophages and T cells in the salivary and lacrimal glands, thus being able to contribute, as an environmental factor, to the onset and exacerbation of the clinical manifestations of SS. Therefore, the investigators hypothesize that a wheat-free diet (WFD) can reduce the inflammatory state and ameliorate the clinical symptoms in SS patients. This hypothesis will be evaluated in both SS patients with associate GI symptoms and in those without GI symptoms. The successive clinical and immunologic reaction to the re-exposure to wheat ingestion, performed by an open challenge, will be also evaluated to confirm a wheat-dependent mechanism and to understand the underlining mechanisms. The project results will provide data about a possible therapeutic role of a WFD in SS and will improve the knowledges about the axis between the intestinal permeability and the systemic inflammation in SS. More specifically, the investigators aim to:
- - identify the prevalence of self-reported NCWS in SS patients; - assess the overall effect that a WFD plus cow's milk products free diet (CMPFD) determines in symptoms control of the patients affected with SS; the investigators decided to include a CMPFD in association with a WFD because, according to several authors, including our previous studies, NCWS, and more generally gluten-related disorders, are often associated with multiple foods intolerance, first of all cow's milk products intolerance; - evaluate, by an open wheat challenge, the real frequency of a coexistent NCWS condition; - assess the possible role played by wheat ingestion in the pathogenesis and molecular mechanisms of SS and NCWS by analysing the variation of intestinal permeability and gut microbiota, in association with cytokines and lymphocytes pattern typical of SS.
Active Comparator: Active Comparator: wheat/milk free diet (W/MFD) group
Patients randomized to intervention group will go to a 2 months elimination diet (wheat and cow's milk products). After 2 months of elimination diet they will go to an open challenge, with reintroduction of wheat. After 2 weeks of open diet or whenever rheumatologic, intestinal and/or extraintestinal symptoms should return or intensify, patients will end the study.
Placebo Comparator: Placebo Comparator: rice/turkey free diet (R/TFD) group
Patients randomized to control group will go to a 2 months elimination diet (rice and turkey's meat). After 2 months of elimination diet they will crossover to a 2 months elimination diet (wheat and cow's milk products). After 2 months of elimination diet they will go to an open challenge, with reintroduction of wheat. After 2 weeks of open diet or whenever rheumatologic, intestinal and/or extraintestinal symptoms should return or intensify, patients will end the study.
Dietary Supplement: - Wheat/milk free diet (W/MFD) group
Patients randomized to intervention diet group will have to follow a wheat and cow's milk products free diet and, after 2 months, they will be exposed to an open wheat challenge, with reintroduction of wheat. After 2 weeks of open diet, or whenever dermatologic, intestinal and/or extraintestinal symptoms should return or intensify, all patients will be revaluated and will end the study.
Dietary Supplement: - Rice/turkey free diet (R/TFD) group
Patients randomized to control diet group will have to follow a diet with elimination of rice and turkey's meat products for 2 months; after that they will crossover to a wheat and cow's milk products free diet and, finally, after 2 months, they will be exposed to an open wheat challenge, with reintroduction of wheat. After 2 weeks of open diet, or whenever dermatologic, intestinal and/or extraintestinal symptoms should return or intensify, all patients will be revaluated and will end the study.
Contact a Trial Team
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Rheumatology Department of the University Hospital of Palermo
Palermo, PA, 90127
Giuliana Guggino, MD
Internal Medicine Division of the "Cervello-Villa Sofia" Hospital
Palermo, PA, 90146
Internal Medicine Department of the University Hospital of Palermo
Palermo, , 90127