“The crackers challenge”: A reassuring low-dose gluten challenge in adults on gluten-free diet without proper diagnosis of coeliac disease

Abstract

BackgroundGluten-free diet (GFD) is the one therapy in coeliac disease (CeD). Unfortunately, some patients adopt GFD before the diagnostic work-up. The guidelines suggest a 14-day gluten intake > 3 gr to get CeD diagnosis, although many subjects refuse this approach. Other evidence showed that the intake of 50 mg/day of gluten for 3 months could be useful for CeD diagnosis. AimsWe performed a dietary study, administering a low dose of gluten in form of “crackers” (about 60–120 mg of gluten/day) for 3 months, to get a final diagnosis of CeD in subjects already on GFD. MethodsWe enrolled adult patients with a suspicion of CeD on self-prescribed GFD. All subjects performed the crackers challenge for 3 months. At the end, all patients were analysed for CeD serology and if positive underwent endoscopy/histology. Also, we recorded the grade of satisfaction for the gluten challenge and the onset of adverse events. ResultsWe enrolled 120 patients. All patients concluded the challenge without relevant adverse events. Serological positivity was detected in 54 patients (45%). Histology showed atrophy in 87% and Marsh 1–2 grade in 13% of patients. Ninety-nine patients (83%) were satisfied by this challenge. ConclusionsThe “crackers challenge” is a useful and safe diagnostic approach in people on self-administered GFD.