Digesting gluten with oral endopeptidases to improve the management of celiac disease

Abstract

In our editorial, we want to comment on the article by Stefanolo et al titled “Effect of Aspergillus niger prolyl endopeptidase in patients with celiac disease on a long-term gluten-free diet”. Celiac disease is an immune-mediated disorder triggered by dietary gluten in genetically predisposed individuals. Although avoiding gluten can permit patients to live symptom-free, ongoing voluntary or involuntary exposure to gluten is common and associated with persistent villous atrophy in small bowel mucosa. As villous atrophy predisposes patients to life threatening complications, such as osteoporotic fractures or malignancies, therapeutic adjuncts to gluten-free diet become important to improve patients’ quality of life and, if these adjuncts can be shown to improve villous atrophy, avoid complications. Oral administration of enzyme preparations, such as endopeptidases that digest gluten and mitigate its antigenicity to trigger inflammation, is one clinical strategy under investigation. The article is about the utility of one endopeptidase isolated from Aspergillus niger. We critique findings of this clinical trial and also summarize endopeptidase-based as well as other strategies and how they can complement gluten-free diet in the management of celiac disease.

Keywords: Celiac disease; Gluten-free diet; Endopeptidase; Villous atrophy; Aspergillus niger; Adjunct therapy

Core Tip: Patients with celiac disease may still be exposed to gluten despite earnest attempts at adhering to a strict gluten-free diet. Gluten-digesting endopeptidases have emerged as an adjunct therapy for celiac disease. Such endopeptidases digest gluten within the gut to prevent its uptake by antigen presenting cells which initiate small bowel inflammation and villous atrophy. The prolyl endopeptidase derived from Aspergillus niger has shown potential to reduce inadvertent dietary gluten exposure and improve patients’ quality of life.