Drug-induced Sprue-like Intestinal Disease

Celiac disease is a gluten-dependent small intestinal disorder with characteristic, but non-specific histopathological features. A number of disorders may cause similar changes in small intestinal biopsies, but fail to respond to a gluten-free diet. Traditionally, infectious agents, such as giardiasis, were often believed to be responsible, but in many patients with a sprue-like intestinal disorder, other causes were detected. The list continues to expand with the emergence of “new” diseases, including transplant enteropathy, distinct immune deficiency syndromes and postcolectomy enteritis, as well as new treatments. Many medications may cause a sprue-like small intestinal mucosal inflammatory process. Alcohol, antibiotics (eg., neomycin), non-steroidal anti-inflammatory drugs (eg., sulindac), stathmokinetic and chemotherapeutic agents (eg., colchicine, vincristine, methotrexate) and immunosuppressive medications (eg., azathioprine, mycophenolate mofetil) may all cause sprue-like small intestinal mucosal changes. A number of “new” drugs have also been recently recognized to cause a sprue-like intestinal disease. These include pharmaceuticals, such as olmesartan, an angiotensin II receptor antagonist used in treatment of hypertension, and biologicals, specifically ipilimumab, a humanized monoclonal antibody designed to overcome cytotoxic T-lymphocyte antigen-4, used in treatment of some advanced malignancies, including malignant melanoma. Increased physician awareness for medication-related sprue-like intestinal disease is critical as the list of emerging and novel medications expands.