The prospective study and the new ESPGHAN protocol L. Greco, D. Mičetić-Turk Mediterranean Network for Celiac Disease Istanbul, June 30th 2012

New recommendations The histology might be omitted in symptomatic cases, who have: - high IgA anti-tTG titres (above 10x upper normal limit), - verified by EMA positivity, - HLA DQ2 and/or DQ8 heterodimer positive.

Who should be tested for CD? Children and adolescents with the otherwise unexplained symptoms and signs Asymptomatic children and adolescents with increased risk for CD

chronic or intermittent diarrhoea failure to thrive weight loss stunted growth delayed puberty amenorrhoea iron-deficiency anaemia nausea or vomiting chronic abdominal pain cramping or distension chronic constipation chronic fatigue recurrent aphthous stomatitis (mouth ulcers) dermatitis herpetiformis-like rash fracture with inadequate traumas / osteopenia / osteoporosis abnormal liver biochemistry Children and adolescents with otherwise unexplained symptoms and signs of:

type 1 diabetes mellitus autoimmune thyroid disease autoimmune liver disease Down’s syndrome Turner syndrome Williams’ syndrome selective IgA deficiency 1st degree relatives with CD dermatitis herpetiformis Asymptomatic children and adolescents with increased risk for CD:

Down syndrome Turner syndrome Dermatitis herpetiformis Dental enamel defects

What is the optimal approach for MEDICEL prospective study?

Diagnosis of CD  history  physical examination diagnostic tools: CD specific antibody tests: Anti-TG 2, anti-DGP, EMA HLA testing for DQ 2 and DQ 8 histological analysis of duodenal biopsies

Diagnosis of CD If you suspect it - you will detect it

New diagnostic tests  serological tests  tissue transglutaminase Ab (t-TG) ‏  reliable, relatively inexpensive test  rapid finger-prick t-TG test

 new microsystems  simultaneus  multiple Ab test  IgA determination  HLA-DQ2/DQ8 status New diagnostic tests Prince HE. Evaluation of the INOVA diagnostics enzyme-linked immunosorbent assay kits for measuring serum immunoglobulin G (IgG) and IgA to deamidated gliadin peptides. Clin Vaccine Imunol Aleanzi M, et al. Celiac disease: antibody recognition against native and selectively deamidated gliadin peptides. Clin Chem. 2001

MEDICEL – prospective study Background CD is a prevalent and curable condition affecting 1% of the population CD is a prevalent and curable condition affecting 1% of the population The occurence of coeliac disease is increasing over time The occurence of coeliac disease is increasing over time CD is more prevalent than clinically detected CD is more prevalent than clinically detected Prevalence among family members ~ 10% Prevalence among family members ~ 10%

Aims To investigate the incidence of CD To investigate the incidence of CD To evaluate characteristics and severity of symptoms To evaluate characteristics and severity of symptoms To estimate CD risk by HLA-SNPs determination in first degree relatives To estimate CD risk by HLA-SNPs determination in first degree relatives To evaluate whether in cases with positive serological and genetic markers and with clinical symptoms the omission of biopsies is possible in Mediterranean countries? To evaluate whether in cases with positive serological and genetic markers and with clinical symptoms the omission of biopsies is possible in Mediterranean countries? Other?? Other??

Study design Prospective multicenter observation study in persons, who will be diagnosed based on: - Standarized symptom assessment - Physical examination - Serology – rapid test or more extensive serology -HLA testing - Histology Conditions for participation: - To recruit at least patients - Ethical approval by the local ethical committee Conditions for participation: - To recruit at least patients - Ethical approval by the local ethical committee

Methods Standarized questionnaire on: family history family history clinical symptoms clinical symptoms and CD related diseases and CD related diseases malignances? malignances?

Methods Blood sampling for serology - central lab / local lab Blood sampling for serology - central lab / local lab 2-5ml blood for TG2, DGP, EMA 2-5ml blood for TG2, DGP, EMA Rapid tTG test Rapid tTG test DNA sampling DNA sampling 2-3ml EDTA blood frozen as total blood (HLA DQ 2 /DQ 8, non-HLA genes) ‏ 2-3ml EDTA blood frozen as total blood (HLA DQ 2 /DQ 8, non-HLA genes) ‏ Saliva sampling Saliva sampling

Methods Histology – at least 5 biopsies from duodenum (4 from 2 nd and 3 rd part and 1 from the bulb) -Marsh criteria Histology – at least 5 biopsies from duodenum (4 from 2 nd and 3 rd part and 1 from the bulb) -Marsh criteria Statistical analysis Statistical analysis Financial calculation Financial calculation Participating clinical centres Sampling and delivery Central / local lab

Data safety Every particiapting centre should treat the patient’s data confidentially. Data analysis -data will be sent encoded to coordinator – Prof Luigi Greco

“Working with the web-database and Biobanking” MEDICEL meeting 2011 Bologna. April Jose Ramon Bilbao

The MediCel database… a newborn project http//medicel.sedyne.org type your name

The MediCel database… a newborn project http//medicel.sedyne.org This is an anonymous database Samples are coded: country_XX This is an anonymous database Samples are coded: country_XX This will be important for follow-up… You should have your code safe with you country_XX = patient ID You should have your code safe with you country_XX = patient ID

The MediCel database… a newborn project http//medicel.sedyne.org

The MediCel database… a newborn project http//medicel.sedyne.org All fields are (*) compulsory! is age at Dx enough? …but are they necessary? …will check Provide HLA testing SNP-based DQ2.5 DQ2.2 DQ8 SNP-based DQ2.5 DQ2.2 DQ8 other genetic studies? Provide affordable HLA testing Provide affordable HLA testing SNP-based DQ2.5 DQ2.2 DQ8 SNP-based DQ2.5 DQ2.2 DQ8

The MediCel database… a newborn project http//medicel.sedyne.org symptoms/signs are we happy?

The MediCel database… a newborn project http//medicel.sedyne.org symptoms/signs are we happy?

Benefits of the study For individuals – diagnosis For individuals – diagnosis For MEDICEL partners For MEDICEL partners ─New knowledge on local level For MEDICEL project For MEDICEL project ─New knowledge – epidemiology of CD in mediterannean countries ─New knowledge – clinical picture ─New knowledge – genetics (non-HLA genes) ‏ Evaluation of new ESPGHAN protocol Evaluation of new ESPGHAN protocol