Do you suspect celiac [disease] if a patient has tested positive for IgG antibodies to any one or more of the wheat protein epitopes plus any one or more of the tissue transglutaminase enzymes?

Okay. Perfect. I love that you’re saying “suspect celiac” because we don’t really diagnose celiac based on the Cyrex Array 3 testing, but remember, if you’re using the classical definition of celiac disease, like, you’re talking with your local gastroenterologist about celiac disease, the markers you’re going to get, you’re going [to] start with a total IgA level and then you’re going to check IgA and IgG tissue transglutaminase antibody. Specifically, in the Cyrex Array 3 panel, that’s tissue transglutaminase 2. Because remember, tissue transglutaminase 2 indicates cross-reactivity with the gut, tissue transglutaminase 3 indicates cross-reactivity with the skin, and tissue transglutaminase 6 cross-reactivity with regions of the brain, and that one we’re thinking more about gluten ataxia. If I’m looking at Cyrex Array 3, one of the antibodies I want to see elevated to kind of start thinking about celiac is going to be tissue transglutaminase 2. Going back to our classic criteria for celiac disease, we’re going to measure total IgA, the IgG [and] IgA of tissue transglutaminase antibody, we’re going to measure IgG [and] IgA of deamidated antigliadin antibody and IgA anti-endomysial antibodies. That’s the blood work that’s generally going to be done for your conventional workup. And again, you might also look at the genetic predisposition DQ2 and DQ8 just to get a better idea in terms of genetic predisposition toward celiac. We don’t have the anti-endomysial antibodies on Cyrex Array 3 or at least the most recent one I know. They keep changing it, but I haven’t seen that one on any of Cyrex Array 3, the directory three. But we do have the deamidated antigliadin, so that’s the one that I’m going to be looking at. We have the native and deamidated alpha-gliadin IgG and IgA. If I see the tissue transglutaminase 2 IgG or IgA, along with the deamidated antigliadin IgG or IgA, that’s when I’m going to be most suspicious of celiac. And again, depending on whether or not there is value for this particular patient and understanding [if] I have the official diagnosis of celiac, I may or may not pursue the anti-endomysial antibody testing through LabCorp and Quest to sort of confirm it.

Otherwise, you mentioned do you distinguish gluten sensitivity as an absence of antibodies to any of the tissue transglutaminases? I would say, if I see pretty much any elevated antibodies on Cyrex Array 3, I’m basically going to call this a non-celiac gluten sensitivity. If I see an elevation in tissue transglutaminase 2 and the deamidated antigliadin antibodies, then I’m going to have a discussion with the patient, and I’m going to say, “Right now, I have to call this non-celiac gluten sensitivity because I cannot confirm a diagnosis of celiac disease, but I’m suspicious [that] you might have celiac disease, and we have the option to do testing through LabCorp or Quest to confirm the diagnosis of celiac if that feels like it would be beneficial or helpful for you.” I would say non-celiac gluten sensitivity; I’m pretty much going to give that diagnosis just seeing antibody levels on that test. If it’s like one or two in the equivocal range, and they’re barely elevated, I’m going to struggle a little bit more in terms of coming down too hard on that, and again, that’s going to be a conversation with the patient about “Well, this gray area, I don’t know …” but certainly, if you have a couple in the red column, [and] a couple in the yellow column, I’m going to say, “Yeah, this looks to me like non-celiac gluten sensitivity.”

Let me go back to the question. I think we covered that. Hopefully, that helps you with the Cyrex Array 3 panel and the celiac testing, specifically.