To propose the hypothesis that non-celiac gluten sensitivity is associated with chronic low-back pain related to spondyloarthritis, and a gluten free diet has a therapeutic benefit in a subgroup of patients. Gut involvement is a well-known association of spondyloarthritis but limited to a few disorders such as inflammatory bowel disease. Currently the therapeutic implication of this association is pharmacologic treatment for inflammation with immunosupresive drugs for both diseases. Here is a case series of patients with chronic low-back pain, spondyloarthritis related features, and response to gluten free diet despite celiac disease being ruled out.
Retrospective case report of 110 patients from a tertiary hospital rheumatology clinic specialized in chronic pain and gluten sensitivity. These are patients with refractory low-back pain and spondyloarthritis features who followed a gluten free diet despite celiac disease being ruled out. Demanding improvement was defined based on the achievement of at least one of the following objectives: asymptomatic status, remission of chronic low-back pain, returning to normal life, returning to work, changing from confinement to bed/wheelchair to being able to walk, returning to self-sufficiency for hygiene and personal care, discontinuation of opioids.
Average age at low-back onset pain was 30. Average disease duration was 15 years. 87 (79%) of the patients experienced improvement. 69 (62%) of the patients achieved demanding improvement. Average duration of gluten-free diet in patients with demanding improvement was 60 months. 56 out of 69 patients with demanding improvement ingested gluten. Of these 56 patients, 54 experienced clinical worsening and were considered as having non-celiac gluten sensitivity. Oral aphthae and having a relative with celiac disease were associated with demanding improvement. Out of 28 patients retrospectively classified as having axial spondyloarthritis, 23 had demanding improvement. Out of 16 patients with uveitis, 13 had demanding improvement. Out of 83 patients with fibromyalgia, 48 had demanding improvement.
These observational data support the proposed hypothesis and offer information regarding possible clinical predictors of response to diet.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.