We appreciate both the interest and the thoughtful comments of Dr Ludvigsson on our study about early atherosclerosis risk in coeliac disease (CD) and its reversal by a gluten-free diet (GFD).[1, 2] It is a pilot study with a number of potential limitations, the most relevant of them being already acknowledged in the manuscript.
As Dr Ludvigsson highlighted, additional selection biases might apply. However, matching patients and controls for body mass index and smoking status was needed for the relevance of these parameters on vascular indices. We are also aware that our reported mucosal response to GFD is at variance with the major literature mentioned. However, most reports are about retrospective evaluation where patients' motivation could not be assessed. Our aim to run a prospective study was also to increase patients' motivation and strict adherence to a GFD in CD. A successful mucosal outcome is consistent with previous experience, where the effect of GFD on small bowel motility in CD was prospectively assessed.
Coeliac disease is an immune disorder with potential damages not only on the target organ but also on vessel walls. We speculated that the removal of the noxious agent in full could be associated with positive, analogue modifications on different sites. However, the strict correlation we found between mucosal and vascular parameter normalisation in gluten abstinent coeliacs was rather unexpected, but obviously welcomed. In addition, our findings are in accordance with observations in other different immune disorders.
As a diagnosis of CD is becoming increasingly common in the general population, we share the point of Dr Ludvigsson that cardiovascular risk pattern in CD patients needs to be thoroughly addressed. As a matter of fact, we are developing a large prospective trial to test our results and any suggestion from referral academic centres is highly appreciated.