Are steroids, such as prednisone (corticosteroid), used to treat severe gluten exposure in celiac disease?

Use of Steroids for Severe Gluten Exposure in Celiac Disease

Steroids are not routinely recommended for treating gluten exposure in celiac disease, with a strict gluten-free diet remaining the cornerstone of management. However, corticosteroids may be considered in specific situations such as refractory celiac disease.

Standard Management of Gluten Exposure in Celiac Disease

• The primary treatment for celiac disease is strict adherence to a gluten-free diet, which leads to reversal of villous atrophy and resolution of symptoms 1
• Accidental gluten exposure typically requires:
  • Immediate return to strict gluten-free diet
  • Supportive care for symptom management
  • Monitoring for nutritional deficiencies

Role of Steroids in Celiac Disease Management

Refractory Celiac Disease

Steroids may be indicated in refractory celiac disease (RCD), which is defined as persistent symptoms and villous atrophy despite strict adherence to a gluten-free diet:

• Open-capsule budesonide (3 mg 3 times daily) has shown 92% clinical response and 89% histologic improvement in RCD 2
• Prednisone (40-60 mg daily with slow taper over several months) has demonstrated:
  • 90% clinical response in RCD type 1
  • 77% clinical response in RCD type 2 2

Evidence for Steroids in Regular Celiac Disease

Limited evidence exists for steroid use in non-refractory celiac disease:

• A pilot randomized controlled trial evaluated adding prednisolone (1 mg/kg for four weeks) to a gluten-free diet in newly diagnosed celiac patients:

  • No significant differences in clinical recovery at 8 weeks
  • No improvement in serological markers
  • Potentially faster histological recovery, though long-term outcomes were similar to gluten-free diet alone 3

• An older study from 1970 showed that prednisolone treatment for 4-5 weeks in adult celiac patients continuing a normal gluten-containing diet resulted in histological, ultrastructural, and enzymic recovery of the jejunal mucosa 4

Clinical Algorithm for Management

1. First-line approach for gluten exposure:

   • Immediate return to strict gluten-free diet
   • Supportive care for symptom management

2. Consider steroids only if:

   • Symptoms are severe and debilitating
   • Patient meets criteria for refractory celiac disease
   • Other causes of symptoms have been excluded

3. When steroids are indicated:

   • For RCD: Open-capsule budesonide (3 mg 3 times daily) or prednisone (40-60 mg daily with slow taper)
   • Monitor for response within 2-4 weeks
   • Plan for gradual taper over several months

Important Considerations and Pitfalls

• Steroids should not replace a gluten-free diet, which remains the cornerstone of treatment
• Avoid long-term steroid use due to significant adverse effects:
  • Short-term: acne, edema, sleep disturbances, mood changes, glucose intolerance
  • Long-term: osteoporosis, adrenal suppression, increased infection risk, hypertension 5
• Always rule out other causes of persistent symptoms, including:
  • Continued gluten exposure
  • Other food intolerances
  • Complications of celiac disease
  • Concurrent conditions

Special Situations

In rare cases, such as the checkpoint inhibitor-induced celiac-like phenotype reported in a case study, symptoms resolved with withdrawal of the causative agent (pembrolizumab) and steroid administration 6, suggesting steroids may have a role in immune-mediated celiac-like conditions.