MEDICATION MANAGEMENT WITH CELIAC DISEASE: PEARLS FOR TECHNICIANS
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MEDICATION MANAGEMENT WITH CELIAC DISEASE:
PEARLS FOR TECHNICIANS
SATURDAY/10:15-11:15AM
ACPE UAN: 0107-9999-17-233-L01-T 0.1 CEU/1.0 hr
Activity Type: Knowledge-Based
Learning Objectives for Pharmacy Technicians:
Upon completion of this CPE activity participants should be able to:
1. Describe celiac disease presentations and pathway to symptoms.
2. Discuss major treatment principles in celiac disease.
3. Utilize resources to determine if a medication is gluten free.
4. List common gluten free medications.
Speaker: Pamela Wiltfang, PharmD, MPH, BA, CHES
Pamela Wiltfang graduated from the University of Iowa in 2012 with Doctor of Pharmacy and
Masters in Public Health degrees. She is currently the Director of Clinical Services &
Innovative Practice for NuCara Management Group, LLC, headquartered in Conrad,
Iowa and oversees all clinical pharmacy services for NuCara locations in Iowa, Illinois,
Minnesota, North Dakota and Texas. In Wiltfang’s current position, she is responsible for developing,
implementing and ensuring success and sustainability of all the clinical programs that NuCara is involved in.
Examples include transitions of care, Wellmark Value Based Pharmacy Practice, New Pharmacy Practice
Model, ACO coordination, care coordination physician-pharmacist programs, and disease state specific
education programs. Wiltfang is also Owner of PFW Consulting, LLC, where she provides high
quality medication therapy management counseling services to high risk patient populations, identifying and
addressing current drug therapy problems with the patient’s primary care providers to improve patient
outcomes and overall health.
Speaker Disclosure: Pamela Wiltfang reports no actual or potential conflicts of interest in relation to this CPE
activity. Off-label use of medications will not be discussed during this presentation.
1/30/2018
Medication
Management in
Celiac Disease:
Pearls for
Technicians
Pamela Wiltfang, PharmD, MPH, BA, CHES
Director of Clinical Services
Disclosure
• Pamela Wong Wiltfang reports no actual or potential conflicts of interest
associated with this presentation
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1/30/2018
Learning Objectives
• Upon successful completion of this activity,
participants should be able to:
- Define celiac disease presentations & its symptoms
- Discuss major treatment principles in celiac disease
- List common gluten free medications
- Utilize resources to determine if a medication is gluten
free
Definition
“Celiac disease is a serious autoimmune disorder that
can occur in genetically predisposed individuals
where the ingestion of gluten leads to damage in the
small intestine…”
-Celiac Disease Foundation
https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/. Accessed: Dec 1, 2017.
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Close-Up
• Finger-like villi absorb nutrients in the small intestine
• In patients with celiac disease, the gluten from wheat, barley, rye, and other grains
is attacked by the body’s immune system
• This immune system’s attack destroys villi on accident, leading to nutrients not able
to be absorbed
Nutrients in GI tract
Nutrients
Nutrients still in GI tract
villa
villa
Normal small intestine Celiac patient small intestine
Nutrients in bloodstream bloodstream
Screening & Testing
• Estimated to affect 1 in 100 people worldwide
• Two populations that should talk with their doctors
about celiac disease:
- Patients with first-degree relatives who have celiac
disease
- Patients with Type 1 diabetes mellitus
• If suspected, a blood test is performed
- A biopsy of the small intestine is required for diagnosis if
the blood test suggests celiac disease
Am J Gastroenterol 2013 May;108(5):656
Evid Based Med 2007 Feb;12(1):24
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Non-Celiac Gluten Sensitivity
• Your blood test for celiac disease came back
negative, but you still don't feel well. Now what?
- Gluten Sensitivity vs. Gluten Intolerence
Approximately 6X’s the
amount of
18 million
Americans
Americans
who have
have gluten
celiac disease
sensitivity
https://www.beyondceliac.org/celiac-disease/non-celiac-gluten-sensitivity/. Accessed: Jan 20, 2017
Non-Celiac Gluten Sensitivity
• Non-specific immune response less severe than celiac
disease
• Causes minimal intestinal damage
• Does NOT appear to be genetically based
• Symptoms typically appear hours or days after gluten has been
ingested
• Overlap of symptoms with celiac disease
- abdominal pain
- fatigue
- headaches
- tingling/numbness
- foggy brain
• Both celiac disease and wheat allergy must be ruled out
https://www.beyondceliac.org/celiac-disease/non-celiac-gluten-sensitivity/. Accessed: Jan 20, 2017
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Disease Presentation – Infants
Classic presentation in infants aged 4-24 months
• When cereals are added to the diet…
- Failure to thrive
• Slowed or stopped physical growth
• Caused by malabsorption of nutrients
- Diarrhea, gas, bloating
- Pale, foul-smelling, or fatty stools
• More common to be diagnosed as a child than adult
Stanford Children’s Health
National Institute of Diabetes and Digestive and Kidney Diseases
Disease Presentation – Adults
Symptoms vary greatly – some patients present with no symptoms
Most common among white, 40-50 year old women with
non-specific symptoms:
- Fatigue
- Anemia
- Changing bowel habits (diarrhea, constipation, bloating, gas)
- Joint pain
- Low-impact bone fracture
BMJ 2014 Mar 3;348:g1561
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Management
NO CURE YET – PREVENTING GLUTEN INTAKE IS KEY!
Lifelong gluten-FREE diet helps manage & avoid symptoms
Symptoms of Gluten Intake Reducing Symptoms of Gluten
(vary greatly but commonly Intake:
include):
• Abdominal discomfort or pain • OTC antihistamine
- Benadryl (diphenhydramine)
• Bloating
• Natural antihistamine
• Swelling - Nettle leaf tea
• Cramping • Warm castor oil pack
• Diarrhea - Place over abdomen
• Headache & sudden “brain fog”
What is “Leaky Gut”?
• Complication or result of celiac disease
• Leaky gut is when the small intestine is damaged
and allows food particles, toxic waste products, and
bacteria to leak into the blood stream which causes
symptoms of celiac disease
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musclegainingsecrets2review.blogspot.com
Disease Management – “Leaky Gut”
• Normal gastrointestinal (GI) tissue is like a tight fabric:
keeping fluids on each side while allowing movement
through the fabric only in certain places
• In celiac disease, it is thought the attack by the immune
system punches holes in the fabric; thus, allowing fluid to
leak back into the small intestines, causing diarrhea and
loose stool
- Commonly called loose junctions
• Certain foods have the ability to help prevent this from
happening
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Disease Management – “Leaky Gut”
• Moderately use or avoid alcohol & NSAIDs
• NSAIDs: Aspirin, Ibuprofen, Naproxen, etc.
• Maintain low & stable blood glucose
• Probiotics with Lactobacillus or Bacillus coagulens
• Controversial: Experts are split on this idea
• Glutamine Supplementation
• Maintains intestinal metabolism & function
• Carnitine (amino acid) Supplementation
• Improves absorption & transportation of essential fatty acids
into cells
• Protects nerve membranes from free radical damage
• Anti-inflammatory diet
ARE PROBIOTICS GOOD OR BAD FOR CELIAC PATIENTS?
• More than half of the top-selling probiotic supplements
contained some gluten, including ones that were labeled as
gluten-free
- A product must contain less than 20 parts per million (ppm) of
gluten to be labeled gluten-free by the FDA
• Some bacterial species belonging to
the Lactobacillus and Bifidobacterium families exert
protective properties in patients with celiac disease
• Gluten Free Probiotic Brands:
- Align, Culturelle, Country Life Power-Dophilus, Kirkman Labs
Pro-Bio Gold Hypoallergenic, Florastor Probiotics
https://www.glutenfreetherapeutics.com/living-gluten-free/medicine-research/are-probiotics-good-or-bad-for-celiac-patients/. Accessed: Jan 16, 2017.
Clin Microbiol Rev. 2014 Jul; 27(3): 482–489.
https://celiac.org/blog/2015/06/probiotics-your-friend-or-foe/. Accessed: Jan 16, 2017.
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Best Better Good
Anti-Inflammatory Food Pyramid
Myths of a Gluten Free Diet
• The gluten-free diet is healthier for people with
gluten-related disorders (celiac disease or gluten
sensitivity)
- NO evidence that it is beneficial for people who do not
have these conditions
• The presence or absence of gluten alone is not
related to diet quality
- What’s important is the overall food choices made within
the diet, whether it’s gluten-free or not
https://www.gluten.org/resources/getting-started/the-gluten-free-diet-facts-and-myths/. Accessed: Jan 16, 2017.
91/30/2018
Myths of a Gluten Free Diet
• Video: The Truth About Gluten
- https://www.webmd.com/diet/video/truth-about-gluten
Common Patient Questions
• What foods do not contain gluten?
• What medications contain gluten?
• How can I see if my medications contain gluten?
• Is there any resources to quickly see if a product
contains gluten?
101/30/2018
What Should Patients AVOID?
• Omega-6’s promote inflammation oil-rich seeds & oils extracted
often in snack foods & fast food
• Carbs promote inflammation bread, potatoes, chips, crackers,
pastries, sweet beverages, high fructose corn syrup
• Meat & poultry promote inflammation
- SUBSTITUTE with vegetable proteins beans, whole grain, nuts
• Fiber products often contain gluten
- Daily Fiber Recommendations:
• 25g for women
• 35-40g for men
• Margarine
• Vegetable shortening
Disease Management – Larazotide
• Knowledgeable patients may have heard about it at their
doctor’s office or online
• Tight junction regulator under development
- Helps with “leaky gut”
• Randomized control trial done in 2015 by Leffler et. al found
the drug reduced signs and symptoms of disease when
used together with a gluten free diet
• Still in clinical trials & not yet approved for the
management of celiac disease
Gastroenterology 2015 Jun;148(7):1311-9.
111/30/2018
Common Gluten-Free Grains, Flours, & Starches
Amaranth Quinoa
Arrowroot Brown Rice
Bean flouts White Rice
Buckwheat Wild Rice
Corn Sorghum Flour
Cornmeal Soy Flour
Potato Flour Tapioca
Potato Starch
Gluten-Containing Products & Ingredients
that Indicate Gluten May Be Present
Alcohol Emmer
Barley Farro
Beer (most contain barley or wheat) Gluten – Gluten Flour
Bleached Flour Graham Flour
Kamut
Bran
Malt – Malt Extract - Malt flavoring
Bulgur
Oats – Oat Bran
Cookie Dough Rye
Couscous
Spelt
Durum Flour
Triticale
Durum Wheat Wheat starch
Einkorn
121/30/2018
Case #1: Patient AL
• A 42 year old male has recently been diagnosed
with celiac disease. Current medications include the
following:
- bupropion SR 150mg (Mylan)
- fluticasone 50mcg nasal spray (Apotex)
- levothyroxine 100 mcg (Sandoz)
- lisinopril 5mg (Solco)
- montelukast 10mg (Mylan)
- tamsulosin 0.4mg (Actavis)
- zolpidem 10mg (Mylan)
How Do I Know a Product is Gluten-FREE?
The safest way to ensure a product is
GLUTEN-FREE is to contact the manufacturer
The Drug Manufacturers Directory
http://www.therubins.com/resource/drugdirect.htm
131/30/2018
Comprehensive List of Medications
http://www.glutenfreedrugs.com/newlist.htm
Dr. Steven Plogsted & Student Pharmacists (Columbus Childrens Hospital, Columbus, OH)
Last Updated 4/28/17
LEGEND
1 = Gluten Free (GF)
2 = Manufacturer doesn’t knowingly add gluten -- since they don’t do any final testing they
won’t guarantee it to be GF but it is very unlikely that it is contaminated with gluten
3 = Contains maltodextrin which occasionally is derived from a wheat source although it has
been deemed safe for persons with celiac disease -- If the source is known it is marked
4 = NOT Gluten Free
5 = According to the manufacturer it is not gluten free however the stated source of gluten is a
sugar alcohol/polyol which are considered gluten free by most experts and generally safe to
take
CS = it contains corn starch (Y = it contains corn starch, N = it does not contain corn starch)
PS = it contains potato starch (Y = it contains potato starch, N = it does not contain potato
starch)
LF = lactose free (Y = it is lactose free, N = it contains lactose)
SF = soy free (Y = it is free of any soy, N = it contains some form of soy
Common Gluten-Free Medications (By Brand Name)
Keep in mind that companies constantly change the ingredients or the way in which the product
is manufactured. Contact the manufacturer directly to ensure the product is gluten-free.
INPATIENT technicians – Medication Reconciliation:
If patients require gluten free medications, BRAND name
medications may be necessary or personal supply may
need to be used if not stocked by the hospital
141/30/2018
Common Gluten-Free Medications (By Brand Name)
Keep in mind that companies constantly change the ingredients or the way in which the product
is manufactured. Contact the manufacturer directly to ensure the product is gluten-free.
Common Gluten-Free Medications (By Brand Name)
Keep in mind that companies constantly change the ingredients or the way in which the product
is manufactured. Contact the manufacturer directly to ensure the product is gluten-free.
Remember to
ALWAYS verify that
the product is gluten
free before
dispensing to a
known celiac patient.
151/30/2018
Case #1: Patient AL
• A 40 year old male has recently been diagnosed with
celiac disease. Current medications include the
following:
- bupropion SR 150mg (Mylan) – GF = gluten free
- fluticasone 50mcg nasal spray (Apotex) – GF
- levothyroxine 100 mcg (Sandoz) – NOT GF
• Switch to Mylan brand generic levothyroxine (GF)
- lisinopril 5mg (Par) – call manufacturer
• Call Par Pharmaceutical: 800-828-9393
- montelukast 10mg (Mylan) – GF
- tamsulosin 0.4mg (Actavis) – NOT GF
• Switch to Mylan brand generic tamsulosin (GF)
- zolpidem 10mg (Mylan) – GF
Dispensing Information
• Make sure to clean the workplace area first as well
as the counting tray if a patient has a gluten allergy
• Cross contamination can be a huge concern with
this patient population
• Although it may take extra time, it is important to
keep patients safe and provide the best care
possible
161/30/2018
Technician Checklist
1. Ask if the patient has any food allergies in addition
to medication allergies
2. If patient has gluten allergy, confirm prescribed
medications are gluten-free
3. Clean workplace & counting tray before dispensing
4. Provide patient with diet education & celiac
disease resources
Confirm
Patient education
Ask patient about prescribed Clean workspace
and celiac disease
any food allergies medications are & counting tray
resources
gluten free
Gluten-Free Cosmetics
• A surprising number of cosmetics contain gluten
• Very little, if any, gluten crosses the skin into the
bloodstream
• Lipstick application close to the mouth
• Several brands now make gluten-free cosmetics and
patients can always call the manufacturers if they are
wanting to know if it contains gluten
• Afterglow, Lily Lolo, Red Apple Lipstick, The Celiac Diva
171/30/2018
Helpful Websites
• Celiac Disease Foundation (celiac.org)
• Meal plans & recipes
• Information on how to get involved in the celiac community and
advocacy efforts
• News updates & webinars
• iCureCeliac
• Free online portal for people who are living with celiac disease or
caregivers to people with a wheat/gluten sensitivity.
• Celiac.com
• Articles, blogs, and frequently asked questions
• Forum for asking your own questions
• Safe food lists and forbidden food lists
Helpful Websites
• Beyond Celiac
• https://www.beyondceliac.org/living-with-celiac-disease/gluten-
in-medication/
• Patient handouts
• Gluten in Medications
• Frequently Asked Questions (FAQs)
181/30/2018
Smart Phone Apps
• The Gluten Free Scanner
• Uses camera to scan barcodes and determine if GF
• Over 500,000 products as of Dec ‘17
• Free for iOS and Android
• Find Me Gluten Free
• Locates local gluten free food in your area
• Contains links for more information from restaurants
• Free for iOS and Android
• ShopWell Healthy Diet & Grocery Food Scanner
• Scan the barcode of food to find it’s ingredients
• Best for busy moms, students & home cooks
• Free for iOS and Android
Smart Phone Apps
191/30/2018
Take Home Points
• Patients with celiac disease cannot ingest gluten
• Screening & testing should be recommended for
those that experience symptoms or have risk factors
• Anti-inflammatory food pyramid is a great resource
• The safest way to ensure a product is gluten-free is
to contact the manufacturer
• Use cross contamination techniques
• Refer patients to helpful websites as well as smart
phone apps
Questions?
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