Tolerability of an Ancient Grain in Patients With Non-Celiac Wheat Sensitivity. A Clinical Study and a Search for Diagnostic Biomarkers.
试验速览
- 阶段
- 不适用
- 状态
- 招募中
- 入组人数
- 68
- 试验地点
- 2
- 主要终点
- Evaluation of gastrointestinal symptoms evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum
研究概览
简要总结
Patients suffering from wheat-related troubles, in absence of celiac disease or wheat allergy diagnosis, can suffer from non-celiac wheat sensitivity (NCWS). This is characterized by both gastrointestinal (GI) and extra-intestinal symptoms, which improve with the elimination of wheat intake. To date no definitive explanation of pathogenetic mechanisms of NCWS has been proved, and, similarly, no specific non-invasive diagnostic biomarker has been recognized. A real need of strict adherence to wheat-free diet (WFD) in NCWS has never been demonstrated. In this context, research is actively trying to find wheat varieties with absent or low immune-reactivity to be used for the treatment of NCWS patients. Preliminary evidence supports the assumption that diploid wheat species, as Triticum monococcum (TM), compared to common ones (Triticum aestivum (TA), could possess a lower immunogenic potential in NCWS patients. The first objective of our project is to verify whether the use of a diploid wheat (TM), with a lower concentrations and bioactivity of Amylase-Trypsin-Inhibitors (ATIs) and with gliadin proteins with a better digestibility, compared to a hexaploid one (TA) could improve both symptoms and quality of life (QoL) of NCWS subjects. The second objective is the identification of non-invasive serological biomarkers for NCWS diagnosis. The third objective is to identify T cell lymphocytes able to recognize cognate peptides from wheat proteins to better classify and monitor patients affected by NCWS. To achieve these results we planned a prospective, double-blind clinical trial with crossover, in which patients already diagnosed with NCWS (according to international criteria and with a double-blind placebo-controlled wheat challenge), following a strict WFD, will be exposed in double-blind to both TM and TA. All the patients will be evaluated clinically at the different timepoints with validated scales to assess tolerability of TM. Moreover, their intestinal permeability, immunological activation and gut microbiota patterns will be studied by both in vitro and in vivo techniques. Finally, a randomly chosen subset of patients will be studied through single cell transcriptome and T-cell receptor (TCR) sequencing on rectoscopy biopsy specimens to identify, T cell lymphocytes able to recognize cognate peptides from wheat proteins.
详细描述
State of the art The association between wheat intake and "wheat-related disorders" (WRDs) has been known for a long time, including pathologies as celiac disease (CD) and wheat allergy (WA). Recently a new non-allergic and non-autoimmune condition has been identified: non-celiac gluten sensitivity (NCGS). This is characterized by both gastrointestinal (GI) symptoms, very similar to those of irritable bowel syndrome (IBS) (eg. abdominal pain, diarrhea, etc.), and extra-intestinal ones (eg. arthromyalgias, anemia, etc.), which improve on a wheat-free diet (WFD).
NCGS prevalence rates range from 0.6% to 13% in the general population, and given the lack of a biomarker, its diagnosis is based on: 1) exclusion of CD and WA; 2) symptom's regression on a WFD; 3) recurrence of symptoms on a double-blind placebo-controlled challenge (DBPCC) with wheat.
Physicians recognize a significant overlap between NCGS and IBS and it is known that IBS affects about 25% of the general population. So, if a percentage of IBS patients could have benefit from a WFD, this would have a paramount impact on its social health costs, being estimated that its indirect costs (eg. loss of work and reduced productivity) are up to $20 billion/years in the US, with an annual cost of $9933 per patient. Furthermore, many patients with IBS-like or upper gastro-esophageal functional-like manifestations self-report a relationship between symptoms onset and wheat ingestion (wheat-intolerance). Nevertheless, a clinical approach with a WFD for all IBS patients would be unmotivated and dangerous, determining also a great economic burden.
In most IBS patients, visceral hypersensitivity may contribute to GI symptoms. Immune activation, due to mucosal mast cells (MCs) in close vicinity to gut nerves, appears to play a role in IBS symptom's onset. A possible neuro-immune interaction in the duodenal submucosa of NCGS patients involving MCs has been described, in order to explain GI symptoms. Other findings in NCGS include an increased infiltration of eosinophils in GI tract, which might produce several inflammatory (ie. eosinophil cationic protein (ECP) and tryptase) and neuromodulatory substances (eg. substance P and VIP).
Several studies have investigated the performance of serum biomarkers panels in differentiating IBS from NCGS and healthy subjects. These included inflammatory cytokines, chemokines, neurotransmitters and antibodies associated with CD. Therefore, it is critically important to investigate the performance of serum biomarkers panels to differentiate "real NCGS" from other conditions.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Crossover
- 主要目的
- Diagnostic
- 盲法
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
盲法说明
Patients will be assigned by a computerized algorithm to start the challenge with the sachets containing triticum monococcum or triticum aestivum. At the end of the first challenge and after an adequate wash-out period, the patients will undergo crossover with the other type of wheat sachets.
The sachets, called A or B, will be completely indistinguishable from each other both in terms of their organoleptic characteristics and the quantity of content (80g of flour) and in terms of their packaging. The company that will supply the flours will be the custodian of the randomization code, and the key will be provided to the experimenters only at the end of all the challenges.
入排标准
- 年龄范围
- 18 Years 至 65 Years（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •age >18 and <65 years;
- •negativity of class A (IgA) and G (IgG) immunoglobulin (Ig) anti-deamidated gliadin (anti-DGP); negativity of IgA and IgG anti-tissue transglutaminase (anti-tTG) and anti-endomysial antibodies (EMA) ;
- •absence of intestinal villous atrophy, documented in all patients carrying the DQ2 and/or DQ8 human leukocyte antigen haplotypes (therefore regardless of the negativity of celiac disease-specific serum antibodies);
- •absence of wheat allergy (negative prick test and/or serum IgE measurement specific to wheat, gluten and gliadin).
排除标准
- •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 drugs abuse;
- •Helicobacter pylori and other bacterial and/or parasitic infections;
- •diagnosis of chronic inflammatory intestinal diseases and other organic pathologies affecting the digestive system (for example, serious liver diseases), nervous system diseases, major psychiatric disorders, immunological deficits and impairments that limit physical activity;
- •patients undergoing chemotherapy and/or radiotherapy.
研究组 & 干预措施
NCWS Packets A-B
NCWS patients will undergo a Double-Blind Wheat Challenge DBWC with an ancient diploid wheat (TM) or a modern hexaploid wheat (TA). This DBWC will be performed with flour packets coded A or B, each containing respectively one of the wheat varieties. Packets A or B will be given for 1 week and then, after 1 week of washout (or until patients report complete well-being), the patients will receive the other packets for another 1 week (cross-over design).
干预措施: Administration of Triticum Monococcum flour (Dietary Supplement)
NCWS Packets A-B
NCWS patients will undergo a Double-Blind Wheat Challenge DBWC with an ancient diploid wheat (TM) or a modern hexaploid wheat (TA). This DBWC will be performed with flour packets coded A or B, each containing respectively one of the wheat varieties. Packets A or B will be given for 1 week and then, after 1 week of washout (or until patients report complete well-being), the patients will receive the other packets for another 1 week (cross-over design).
干预措施: Administration of Triticum Aestivum flour (Dietary Supplement)
NCWS Packets B-A
NCWS patients will undergo a Double-Blind Wheat Challenge DBWC with an ancient diploid wheat (TM) or a modern hexaploid wheat (TA). This DBWC will be performed with flour packets coded A or B, each containing respectively one of the wheat varieties. Packets A or B will be given for 1 week and then, after 1 week of washout (or until patients report complete well-being), the patients will receive the other packets for another 1 week (cross-over design).
干预措施: Administration of Triticum Aestivum flour (Dietary Supplement)
NCWS Packets B-A
NCWS patients will undergo a Double-Blind Wheat Challenge DBWC with an ancient diploid wheat (TM) or a modern hexaploid wheat (TA). This DBWC will be performed with flour packets coded A or B, each containing respectively one of the wheat varieties. Packets A or B will be given for 1 week and then, after 1 week of washout (or until patients report complete well-being), the patients will receive the other packets for another 1 week (cross-over design).
干预措施: Administration of Triticum Monococcum flour (Dietary Supplement)
结局指标
主要结局
Evaluation of gastrointestinal symptoms evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum
时间窗: Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization)
A modified version of Gastrointestinal Symptom Rating Scale (GSRS) will be administered to all the patients during each outpatient visit to assess gastrointestinal symptoms before the challenge (T0, wheat free diet) and after exposure to both Triticum Monococcum (TM) and Triticum Aestivum (TA). Difference will be considered relevant if GSRS will be recorded \>30% compared to T0 and/or to any eventual increase determined during the administration of the other wheat variety.
Evaluation of extraintestinal symptoms evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum
时间窗: Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization)
A extraintestinal symptoms rating scale, based on the symptoms most frequently observed in NCWS patients, will be administered to all the patients during each outpatient visit to assess gastrointestinal symptoms before the challenge (T0, wheat free diet) and after exposure to both Triticum Monococcum (TM) and Triticum Aestivum (TA). Difference will be considered relevant if extraintestinal symptoms rating scale will be recorded \>30% compared to T0 and/or to any eventual increase determined during the administration of the other wheat variety.
Evaluation of quality of life modification evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum
时间窗: Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization)
The Irritable Bowel Syndrome-Quality of Life (IBS-QoL) will be used to assess patient's QoL. It is an already validated condition-specific tool for IBS patients, which incorporates specific subdomains, such as food avoidance, bowel habits, and the effect on the social/sexual relationships. IBS-QoL will be administered to all the patients during each outpatient visit to assess gastrointestinal symptoms before the challenge (T0, wheat free diet) and after exposure to both Triticum Monococcum (TM) and Triticum Aestivum (TA). Difference will be considered relevant if IBS-QoL will be recorded \>30% compared to T0 and/or to any eventual increase determined during the administration of the other wheat variety.
次要结局
- Analysis of modification of serological indexes of intestinal permeability evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: zonulin(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal permeability evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: occludin(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal injury evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: intestinal fatty acid-binding protein(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- In vivo evaluation of intestinal permeability modification evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal injury evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: lipopolysaccharide(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal injury evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: lipopolysaccharide binding-protein(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal injury evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: F-actin immunoglobulin (Ig)A(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal permeability evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: claudin 1(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of serological indexes of intestinal injury evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: F-actin immunoglobulin (Ig)G(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: somatostatin(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the humoral immune response to gluten evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: anti-gliadin antibodies immunoglobulin G(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: granulocyte colony-stimulating factor(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-4(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: vasoactive intestinal peptide(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interferon (IFN)-γ(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-1β(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: substance P(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: eosinophil cationic protein(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: serotonin(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of gut hypersensitivity indexes evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: tryptase(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: granulocyte-macrophage colony-stimulating factor(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-5(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the humoral immune response to gluten evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: anti-gliadin antibodies immunoglobulin A(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-2(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-9(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-12(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-13(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Identification of T cell lymphocytes able to recognize cognate peptides from wheat proteins(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-6(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-8(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-15(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-17(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-21(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-33(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-10(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of immunophenotyping of whole blood for quantification of immune cell (IC) subpopulations modification and their activation status evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of gut microbiota modification evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: interleukin (IL)-22(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
- Analysis of modification of the serological inflammatory biomarkers evoked by dietary exposition to Triticum Monococcum and Triticum Aestivum: tumor necrosis factor (TNF)-α(Days 0 (before start of challenge), 7 (after intake of first kind of flour according randomization) and 21 (after intake of second kind of flour according randomization))
研究者
Pasquale Mansueto
Associate Professor
University of Palermo