Letter: atherosclerosis and coeliac disease - another feature of the changing paradigm? Authors' reply

We wish to thank Dr Valitutti and coworkers for the critical appraisal regarding our study about early atherosclerosis risk in coeliac disease (CD).1, 2 The study is indeed a pilot study with a small number of cases and other limitations we have acknowledged in the manuscript. Dr Valitutti pointed out some selection biases that are present. However, the matching of patients and controls for BMI and smoking habits was needed for their influence on the vascular parameters considered. Regarding the high rate of mucosal recovery we have obtained, we are aware of the difference with other data in the literature; in fact, most of these studies are retrospective evaluations, whereas we conducted a prospective protocol trying to increase patients' motivation and strict adherence to diet. A similar successful mucosal outcome can be observed in a previous similar experience.3 In addition, we acknowledge that the population studied may not be representative of the whole Italian CD population, but limiting recruitment to young people was a must in order to avoid confounding issues in terms of atherosclerosis risk. While the recovery in intima-media thickness was more difficult to observe being a structural alteration, a recovery in endothelium-dependent dilatation was somehow expected as this parameter can be improved also with short-term modifications and therapies.4, 5 Furthermore, we definitely agree with Dr Valitutti that these data should be confirmed in large studies avoiding the structural biases of our protocol. We think the value of our work is to signal some interesting findings that can be stimulating in developing more investigations. Another interesting point may regard a methodological perspective: in this pathological setting, we can face an autoimmune disease that produces damage on a target organ and on vasculature, we can analyze it and remove the noxious agent from the diet, we can try to recognise the reversal of damage, a unique plain model. As a matter of fact, we are developing a prospective trial to test our results and any suggestion from academic referral centres is highly appreciated. We wish again to thank Dr Valitutti and AP&T for this welcomed opportunity of debating our work. The authors' declarations of personal and financial interests are unchanged from those in the original article.2