More Sensitive Detection of Gluten Free Diet Adherence

A recent cross-sectional study (K Gerasimidis et al. JPGN 2018; 67: 356-60) examined the use of fecal gluten immunogenic peptide (GIP) to assess for adherence with gluten free diet (GFD) in biopsy-proven celiac disease (CD).

GIP reflects recent gluten consumption.  There is a commercially-available kit available (Ivydal GIP Testing) –though I am uncertain about how its reliability compares to the GIP measured in this study.

In the study, the authors note that GIP positivity can occur with as little as 100 mg of gluten/day ingestion.  GIP is a 33-mer peptide from α2-gliadin that is stable against breakdown by gastric, pancreatic, and intestinal brush border enzymes.

Key findings of this study:

  • GIP was detectable in 16% of patients with previous CD diagnosis (N=67)
  • GIP was detectable in 95% of newly-diagnosed CD patients (n=19) and was detectable in 27% at 1 year afterwards.
  • When compared with traditional indicators of GFD adherence (eg. TTG levels, Biagi score, clinical assessment), 4 out of 5 children with detectable GIP were missed

My take: Fecal GIP for celiac disease adherence has similar potential as a biomarker as calprotectin has for IBD.  A normal GIP appears to be much more sensitive at detecting gluten ingestion.

Related blog posts:

Low Adherence Rate with Polyethylene Glycol

The sentiment of wanting to get their kid off laxatives/stool softeners is frequently expressed at GI visits.  I certainly understand this.  Though, if a child is not stooling adequately when these medicines are withheld, this is usually detrimental for the child.

Given the frequency of this sentiment, it is not surprising that a recent study (IJN Koppen et al. J Pediatr 2018; 199: 132-9) reports low adherence with polyethylene glycol treatment in children with functional constipation.

In this cross-sectional survey using the Medication Adherence Report Scale (MARS-5), with scores of ≥23 indicating better adherence, the authors found that only 43 of 115 (37%) children were adherent.  The authors note that one of the determinants of adherence was treatment convenience.

The MARS-5 does not objectively measure the exact intake of medication; thus, the exact rate of adherence is unclear.  In addition, there is likely to wide variation in adherence among different populations.

My take: this study shows, at least in some populations, a low adherence with constipation therapy.  Sticking with treatment, for constipation and every other condition, usually results in better outcomes.

Related blog posts:

If someone is not taking their medication, perhaps this cereal would help. (I am not officially endorsing this product, but think the name is funny.)

Challenging Assumptions: Self-Management Adolescent Skills and Poor Outcomes

If you think that teaching more self-management to adolescents will lead to better outcomes, you might be wrong.  A recent study (RA Annunziato et al. J Pediatr 2018; 193: 128-33) shows that adolescents who reported greater self-management, following liver transplantation, had worse outcomes.

In this study of 9-17 year olds and their parents (213 dyads), the key finding was based on a score derived from the REFILS survey.  REFILS is an acronym for “Responsibility and Familiarity with Illness Survey.”  This survey was curtailed from 22 items to the following 13 items:

  • Understands key aspects of liver disease
  • Discusses management plan with team
  • Self-manages liver regimen
  • Knows names/dose of medications
  • Keeps track of medications
  • Correctly takes medications
  • Calls pharmacy for refills
  • Knows different types of providers
  • Knows date of next appointment
  • Makes appointments
  • Know insurance details
  • Understands insurance plan
  • Keeps healthcare records

Key finding:

  • “Negative outcomes were more likely to occur if patients reported that they are ‘in charge.’ A higher [REFILS] score, which denotes a higher level of (self-reported) management, was significantly and consistently correlated with worse adherence and organ rejection.”

The implication is that the transition of responsibilities from the parent/caregiver to the adolescent “may in fact not always be indicated or advisable…education about self-care might actually be harming patients…It is probably prudent to discourage rather than encourage adolescents from assuming self-care in some cases.”

My take: While adolescents and young adults are capable in many aspects, there are hardly any that I would trust to care for our dog (see below) for any protracted period.  Thus, in my view, without close parental supervision, entrusting the life of a liver transplant recipient to an adolescent is risky.

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What is Your Infliximab Adherence Rate?

I started thinking about this question after a recent study (DS Vitale, et al. JPGN 2015; 61: 408-10) examined adherence at a single pediatric center (2010-2012). Adherence indicated “those who attended >80% of scheduled infusions.” Key findings:

  • 91.4% adherence rate of patients (n=151 with >4 infusions)
  • Adherent patients (n=138) attended an average of 98% of their infusions. Nonadherent patients attended, on average, 76% of their infusions.
  • The study provided some preliminary evidence that there was greater acute care use in nonadherent patients.
  • There were no demographic features that could predict adherence pattern.

My take: One of the key advantages of infusion therapy is improved and documented adherence.  Infusions also provide opportunities to assess patient in a scheduled manner. This study shows that subsets of patients with scheduled infusions have suboptimal adherence  — another target for quality improvement!

Atlanta Botanical Gardens, Bruce Munro Exhibit

Atlanta Botanical Gardens, Bruce Munro Exhibit