Entry to the list of donations to the Foundation transparent account

Type 1 Diabetes and Celiac Disease

January 30th, 2016 | by American Association

Type 1 Diabetes and Celiac Disease: Overview and Medical Nutrition Therapy

Capture

  1. Sarah Jane Schwarzenberg, MDand 
  2. Carol Brunzell, RD, CDE

In patients with celiac disease (gluten-sensitive enteropathy, or GSE), ingestion of the gliadin fraction of wheat gluten and similar molecules (prolamins) from barley, rye, and possibly oats causes damage to the intestinal epithelium. The injury results from an abnormal T-cell response against gliadin. Thus, GSE is a disease in which host susceptibility must be combined with a specific environmental trigger to affect injury.1

Typically, patients with GSE have chronic diarrhea and failure to thrive. However, some patients present with short stature, flatulence, or recurrent abdominal pain. Dermatitis herpetiformis, a pruritic papular rash, is directly related to GSE.2 Other atypical presentations are increasingly recognized, among them iron-deficiency anemia, osteopenia/osteoporosis, short stature, dental enamel hypoplasia, arthritis and arthralgia, chronic hepatitis/hypertransaminasemia, and neurological problems. GSE has also been found in asymptomatic individuals who nonetheless have evidence of intestinal mucosal injury on biopsy.1

 

Celiac Disease and Type 1 Diabetes

An association of diabetes with GSE has been observed since the late 1960s. In recent years, it has become clear that the incidence of GSE in patients with type 1 diabetes is substantial. A prevalence rate of 4–6% in type 1 diabetes has been reported.3–5 Some of the variation in prevalence can be attributed to the different diagnostic criteria used in the studies.

The majority of patients with GSE are asymptomatic4 or are not aware of symptoms. Some patients present with problems recognized only retrospectively as resulting from celiac disease; it is common for “asymptomatic” patients to report improved health or sense of well-being when following a gluten-free diet. Up to one-third of patients may have unexplained failure to thrive, abdominal pain, or short stature.3,6

More controversial is the question of whether GSE affects blood glucose control. A study by Acerini et al.7 in a type 1 diabetic population found no difference between the celiac and non-celiac subpopulation in terms of hemoglobin A1c or total insulin needs. Some celiac patients had morning hypoglycemia after starting a gluten-free diet, but no statistically significant change in insulin needs was found. Another study8 of adults with type 1 diabetes and GSE found no difference in metabolic control of diabetes with treatment of GSE.

It has been observed that patients with GSE have hypoglycemic episodes and reduced insulin needs before diagnosis, presumably because of malabsorption.9 In a detailed study of growth parameters, blood glucose control, and dietary intake in a group of children and adolescents with GSE and type 1 diabetes, Westman et al.10 found no differences between GSE and non-GSE patients. This population was screened annually for GSE and so were diagnosed at an asymptomatic point of the illness. In a case-controlled study of the incidence of hypoglycemia in patients with untreated GSE, Mohn et al.11 found that there were significantly more episodes of hypoglycemia in the GSE patients than in controls. Institution of a gluten-free diet reduced hypoglycemia, but only several months after initiation.

It seems likely that a malabsorptive disease could create opportunity for hypoglycemia in diabetes, particularly in patients under tight control. Serological testing for GSE in patients with type 1 diabetes, with early diagnosis of GSE, may reduce this risk by allowing patients to be diagnosed in a pre-symptomatic state. It also seems prudent to closely monitor insulin needs and blood glucose control during the early phase of instituting a gluten-free diet.

Testing People With Diabetes for GSE

Serological testing is an important screening tool for patients with atypical or silent celiac disease or family members of patients with GSE. While the evolving nature of serological testing for GSE makes any recommendation difficult, most investigators would advocate a profile consisting of three antibody assays: 1) anti-gliadin IgG, 2) anti-gliadin IgA, and 3) either an anti-endomysial or an anti-tissue transglutaminase assay. Serum IgA must be quantitated in all patients because the most specific antibodies are IgA, and GSE is more common in patients with IgA deficiency.12–14

Patients with positive serological tests and those who have symptoms compatible with GSE and negative serology should be referred to a gastroenterologist for further diagnostic studies. In the past, the diagnosis of GSE required three small-bowel biopsies generally performed endoscopically. The first, done while the patient was symptomatic, would show mucosal injury. A second biopsy would be performed after a minimum of 1 year on a gluten-free diet. If those results were normal, the patient then would be challenged carefully with gluten, and a third biopsy, which would again show abnormalities, would be performed either when the patient was symptomatic or after 1 year on gluten.15 The evolution of serological testing has allowed modification of this protocol, although individual patients may still require multiple biopsies to distinguish GSE from diseases that produce a similar histopathological injury.16

There are limitations to serological testing. First, a positive serological test is not diagnostic of GSE. Small-bowel biopsy is required to confirm the diagnosis. Second, patients under the age of 2 years may have false-negative results on serology. When celiac disease is strongly suspected in patients within this age-group, they should have a small-bowel biopsy despite negative antibody testing. If they are asymptomatic, they should be re-tested at an older age. Third, it is clear that a single serological test with negative results does not preclude the later development of celiac disease. Although clear recommendations are not available, many centers test yearly for the first 3 years of diagnosed diabetes, every 3–5 years thereafter, and whenever symptoms develop.

Treatment of GSE

Current U.S. and Canadian recommendations for the treatment of GSE include a strict gluten-free diet to be maintained for life. For many patients with diabetes, this may seem unreasonable given the changes they have no doubt already made to their diet after their diabetes diagnosis. However, the stringency of this recommendation is based on sound reasoning.

First, strict elimination of gluten has been shown to lower the risk of small-bowel lymphoma associated with GSE.17 Although there are no reliable incidence figures for lymphoma in GSE, a recent survey by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition18 reported five cases of small-bowel lymphoma with responses from about half their membership. All five patients were eating gluten. It should be noted that this reflects only the lymphoma diagnoses in children in this region; the risk may rise in adults, particularly if the diet is not maintained. This constitutes the most compelling reason to advocate strict adherence to the diet.

Many GSE patients, despite their resistance to the diet, find they feel better and have more energy when their diets are gluten-free. Frequently, both children and adults have more energy, feel less irritable and cranky, display better skin color, and report better overall health following treatment of GSE. Some people with diabetes and GSE report that blood glucose control is easier to maintain when they follow the gluten-free diet. While these are not universal benefits, they should be noted in discussions with patients.

Finally, patients with untreated celiac disease are at risk of multiple deficiencies of micronutrients and vitamins because of the malabsorption of these nutrients by the injured small intestine. Among the reported problems are iron and vitamin B12 deficiency. At diagnosis, many celiac patients have osteopenia, which resolves on a gluten-free diet. Clearly, the risk of malnutrition is another important reason to advocate a strict gluten-free diet.

Celiac disease is a lifelong condition; thus, the diet is a permanent change for these patients. Many patients become exquisitely sensitive to the ingestion of even small amounts of gluten after a gluten-free period. Violent vomiting, severe diarrhea, abdominal cramping, and even shock may occur in these patients.

In some patients, ingestion of small amounts of gluten will not produce overt symptoms. Some patients experience a reduction in response to gluten during their teens—the so-called “honeymoon period.” Unfortunately, despite the lack of perceived symptoms, biopsies of the small intestine in these patients demonstrate ongoing mucosal injury associated with gluten ingestion. It is believed that this persistent recurrent injury to the intestine is the factor that predisposes these patients to lymphoma. Thus, absence of symptomatic response to gluten ingestion should not be construed as indicating that gluten intake is safe.

To aid patients in maintaining the diet, they should be tested regularly for ingestion of gluten (at least yearly and perhaps more often for those who have difficulty following the diet). Antigliadin antibodies rise within weeks of gluten ingestion in patients with GSE and constitute a useful marker of dietary management. Patients may inadvertently ingest gluten because of its abundant use in many prepared foods. Contamination of gluten-free foods in a family toaster full of wheat crumbs, for example, may be discovered by interviewing the family after a positive antigliadin antibody test.

Most studies suggest that osteopenia and vitamin and mineral deficiencies associated with GSE resolve on the gluten-free diet. Thus, in patients adhering to the diet, little long-term screening for these deficiencies is warranted.

It should be noted that immediately after diagnosis, some supplements and dietary modifications may be necessary that will be unnecessary after the intestinal mucosa is healed. Patients are frequently lactose-intolerant at diagnosis because of injury to the di-saccharidases in the small intestine. Patients should be screened at diagnosis for iron, zinc, B12, folate, calcium, magnesium, and fat-soluble vitamin deficiencies and treated if abnormalities are found. Most specific supplements can be stopped 6–12 months into therapy.

Because gluten-free foods may be lower in B vitamins, folate, iron, and fiber, careful planning is necessary to ensure adequate intake of these nutrients.19,20 A daily multivitamin may be recommended for patients with GSE.

The Diet

Ideally, a gluten-free diet would eliminate any prolamin or similar protein capable of stimulating an adverse T-cell response. (SeeTables 1 and 2.) Unfortunately, there is no way to directly determine the capacity of individual grains to elicit a response, and current recommendations rely on in vivo testing. As a result, there is controversy regarding the most appropriate diet for patients with GSE. For example, moderate consumption of oats has been shown in several short-term studies to be safe;21–24 however, many celiac organizations and the American Dietetic Association are not yet recommending oats as safe for consumption. It is also unclear whether several other grains, such as buckwheat and amaranth, are acceptable on a gluten-free diet.25 A consensus is needed among the various organizations to minimize confusion for practitioners and patients.26

Codex Standards

The Codex Alimentarius Commission of the World Health Organization and the Food and Agriculture Organization of the United Nations provides the only international gluten-free food standards for manufacturers. The standards for gluten-free foods as defined by the commission allow small amounts of prolamin in foods that are designated gluten-free.27 In Europe, the United Kingdom, and Scandinavia, ingestion of wheat starch that has been rendered gluten-free is permitted. European Codex Alimentarius-quality wheat starch has been used in some European countries for several decades and is considered safe.28 However, the United States and Canada have adopted a strict gluten-free regimen and do not recommend the use of wheat starch that contains small amounts of toxic prolamins until further studies can confirm its safety.29

It is important to inform patients traveling to countries adhering to Codex standards of this labeling discrepancy. In addition, individuals in the United States and Canada should be aware that the term “gluten-free” on imported foods purchased through direct mail order may not have the same implication it would if the food were produced locally.

Other Hidden Sources of Gluten

Complete removal of gluten-containing grains is challenging. Hidden sources of gluten/prolamins may be found in the ingredients of many processed foods in the form of additives, stabilizers, thickeners, flavorings, extracts, emulsifiers, hydrolyzed textured vegetable proteins, and certain ground spices. Other sources of prolamins include grain alcohol, some prescription and over-the-counter medications, certain multivitamins, toothpastes, lip balms, mouthwash, and adhesive on stamps and envelopes. Ingredient reference lists are extensive and must be available to all patients and health care providers. Patients with dermatitis herpetiformis need to check labels and/or manufacturers for prolamins in lotions, creams, and cosmetics. Patients must become lifelong label readers because ingredients in food and non-food items may change over time.

The potential for cross-contamination is also of concern. Equipment used for processing and shipping grains (bins, rail cars, trucks) and grains sold in bulk at natural food sections/stores may be contaminated via cross-use of equipment, bins, and scoops with prohibited grains.

Eating in restaurants poses additional challenges. A gluten-free item may be cooked in a pan or on a grill that is also used to cook problem foods and that may not be cleaned between food orders. Deep-fat fryers are also a source of contamination. Patients must be prepared to ask detailed questions about menu items and preparation.

Cross-contamination in the home may occur from toasters, kitchen counters, and containers of jam, peanut butter, and other spreads. Some patients have separate cooking utensils, toasters, mixers, storage containers, and other kitchen items. Health care institutions, diabetes camps, daycare providers, schools, and other care providers must be knowledgeable about gluten-free diets and the potential for cross-contamination.

Educational Materials

Referring patients to a registered dietitian who has expertise in medical nutrition therapy (MNT) for GSE is imperative. An MNT protocol has been developed and is a valuable tool for ensuring comprehensive education for patients with GSE.30 Patients also must be strongly encouraged to join national and local support groups (Table 3) for access to the latest information, educational materials, and support.

There is a need for educational materials that combine MNT for celiac disease and MNT for diabetes. Gluten-free foods are not always equivalent in carbohydrates to similar gluten-containing foods. Other diabetes educational materials, such as instructions for treatment of hypoglycemia with specific foods, should also be available in versions for patients with GSE.

Because of the overwhelming number of foods containing gluten, intensive patient training is imperative. Dietitians must be prepared to help patients navigate the conflicting information from various organizations and health care providers.

 

Footnotes

  • Sarah Jane Schwarzenberg, MD, is an associate professor of pediatrics in the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at the University of Minnesota in Minneapolis. Carol Brunzell, RD, CDE, is a diabetes educator at Fairview-University Medical Center Diabetes Education and Self-Management Program, Pediatric and Adult Divisions, in Minneapolis, Minn.
  • American Diabetes Association

Picture 1.:

T1.medium

 

 

 

 

 

 

 

 

 

Picture 2.:

T2.medium

 

 

 

 

 

 

 

 

 

 

References

  1. Fasano A, Catassi C: Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum.Gastroenterology 120:636–651, 2001
  1.  Reunala T, Collin P: Diseases associated with dermatitis herpetiformis. Br J Dermatol 136:315–318, 1997
  1. Aktay AN, Lee PC, Kumar V, Parton E, Wyatt DT, Werlin SL: The prevalence and clinical characteristics of celiac disease in juvenile diabetes in Wisconsin. J Pediatr Gastroenterol Nutr33:462–465, 2001
  1. Cronin CC, Feighery A, Ferriss JB, Liddy C, Shanahan F, Feighery C: High prevalence of celiac disease among patients with insulin-dependent (type I) diabetes mellitus. Am J Gastroenterol 92:2210–2212, 1997
  1. Vitoria JC, Castano L, Rica I, Bilbao JR, Arrieta A, Garcia-Masdevall MD: Association of insulin-dependent diabetes mellitus and celiac disease: a study based on serologic markers.J Pediatr Gastroenterol Nutr 27:47–52, 1998
  1. Madacsy L, Arato A, Korner A: Celiac disease as a frequent cause of abdominal symptoms in children with insulin-dependent diabetes mellitus. Clin Pediatr (Phila) 36:185–186,1997
  1. Acerini CL, Ahmed ML, Ross KM, Sullivan PB, Bird G, Dunger DB: Coeliac disease in children and adolescents with IDDM: clinical characteristics and response to gluten-free diet. Diabet Med 15:38–44, 1998
  1. Kaukinen K, Salmi J, Lahtela J, Siljamaki-Ojansuu U, Koivisto AM, Oksa H, Collin P: No effect of gluten-free diet on the metabolic control of type 1 diabetes in patients with diabetes and celiac disease: retrospective and controlled prospective survey. Diabetes Care 22:1747–1748, 1999
  1. Iafusco D, Rea F, Chiarelli F, Mohn A, Prisco F: Effect of gluten-free diet on the metabolic control of type 1 diabetes in patients with diabetes and celiac disease. Diabetes Care23:712–713, 2000
  1. Westman E, Ambler GR, Royle M, Peat J, Chan A: Children with celiac disease and insulin dependent diabetes mellitus: growth, diabetes control and dietary intake. J Pediatr Endocrinol Metab 12:433–442, 1999
  1. Mohn A, Cerruto M, Lafusco D, Prisco F, Tumini S, Stoppoloni O, Chiarelli F: Celiac disease in children and adolescents with type I diabetes: importance of hypoglycemia. J Pediatr Gastroenterol Nutr 32:37–40, 2001
  1. Leon F, Camarero C, R-Pena R, Eiras P, Sanchez L, Baragano M, Lombardia M, Bootello A, Roy G: Anti-transglutaminase IgA ELISA: clinical potential and drawbacks in celiac disease diagnosis. Scand J Gastroenterol 36:849–853, 2001
  1. Roldan MB, Barrio R, Roy G, Parra C, Alonso M, Yturriaga R, Camarero C: Diagnostic value of serological markers for celiac disease in diabetic children and adolescents. J Pediatr Endocrinol Metab11:751–756, 1998
  1. Russo PA, Chartrand LJ, Seidman E: Comparative analysis of serologic screening tests for the initial diagnosis of celiac disease. Pediatrics 104:75–78, 1999
  1. Meeuwisse GW: Diagnostic criteria in coeliac disease. Acta Paediatr Scand 59:461–463, 1970
  1. Walker-Smith JA, Guandalini S, Schmitz J, Shmerling DH, Visakorpi JK: Revised criteria for diagnosis of coeliac disease.Arch Dis Child 65:909–911, 1990
  1. Holmes GK: Celiac disease and malignancy. J Pediatr Gastroenterol Nutr 24:S20–S24, 1997
  1. Schweizer JJ, Oren A, Mearin ML: Cancer in children with celiac disease: a survey of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 33:97–100, 2001
  1. Thompson T: Thiamin, riboflavin, and niacin contents of the gluten-free diet: is there a cause for concern? J Am Diet Assoc99:858–862, 1999
  1. Thompson T: Folate, iron, and dietary fiber contents of the gluten-free diet. J Am Diet Assoc 100:1389–1396, 2000
  1. Janatuinen EK, Pikkarainen PH, Kemppainen TA, Kosma V-M, Jarvinen RMK, Uusitupa MIJ, Julkunen RJK: A comparison of diets with and without oats in adults with celiac disease. N Engl J Med 333:1033–1037, 1995

 

  1. Janatuinen EK, Kemppainen TA, Pikkarainen PH, Holm KH, Kosma V-M, Uusitupa MIJ, Maki M, Julkunen RJK: Lack of cellular and humoral immunological responses to oats in adults with coeliac disease. Gut46:327–331, 2000

 

  1. Picarelli A, Ki Tola M, Sabbatella L, Gabrielli F, Di Cello T, Anania MC, Mastracchio A, Silano M, De Vincenzi M: Immunologic evidence of no harmful effect of oats in celiac disease. Am J Clin Nutr74:137–140, 2001
  1. Srinivasan U, Leonard N, Jones E, Kasarda DD, Weir DG, O’Farrelly C, Feighery C: Absense of oats toxicity in adult coeliac disease. BMJ 313:1300–1301, 1996

 

  1. Thompson T: Case problem: questions regarding the acceptability of buckwheat, amaranth, quinoa, and oats from a patient with celiac disease. J Am Diet Assoc 101:586–587, 2001
  1. Thompson T: Questionable foods and the gluten-free diet: survey of current recommendations. J Am Diet Assoc 100:463–465, 2000
  1. Joint FAO/WHO Food Standards Program: Codex Committee on Nutrition and Foods for Special Dietary Uses: Draft revised standard for gluten-free foods. CX/NFSDU 98/4. July, 1998:1–4
  1. Kaukinen K, Collin P, Holm K, Rantala I, Vuolteenaho N, Reunala T, Maki M: Wheat starch-containing gluten-free flour products in the treatment of coeliac disease and dermatitis herpetiformis: a long-term follow-up study. Scand J Gastroenterol 34:163–169, 1999

 

  1. Thompson T: Wheat starch, gliadin, and the gluten-free diet.J Am Diet Assoc 101:1456–1459, 2001

 

  1. Inman-Felton AE: Overview of gluten-sensitive enteropathy (celiac sprue). J Am Diet Assoc 99:352–362, 1999

T3.medium

 

Ratings article

1 Star2 Stars3 Stars4 Stars5 Stars (No Ratings Yet)
Loading...Loading...

441 Comments

  1. Pingback: get more info

  2. Pingback: http://www.mejaqq11.site/

  3. Pingback: https://funkymedia.pl/

  4. Pingback: ignou synopsis

  5. Pingback: جلب الحبيب

  6. Pingback: porn

  7. Pingback: maquiagem gif

  8. Pingback: dominoqq

  9. Pingback: 안전카지노

  10. Pingback: 바카라 사이트 웹툰

  11. Pingback: child porn

  12. Pingback: viagra women

  13. Pingback: goodrx cialis

  14. Pingback: generic for cialis

  15. Pingback: Buy viagra from canada

  16. Pingback: generic for ciprofloxacin

  17. Pingback: cialis 20mg

  18. Pingback: video promotionnel

  19. Pingback: cheap cialis

  20. Pingback: THC vape juice

  21. Pingback: Study in Uganda

  22. Pingback: mẹ mua em heo đất

  23. Pingback: Buy Adderall Online

  24. Pingback: online pharmacy viagra

  25. Pingback: seo prutser

  26. Pingback: canadian pharmacy

  27. Pingback: canadian pharmacy

  28. Pingback: Buy cialis online

  29. Pingback: cialis online

  30. Pingback: buy levitra

  31. Pingback: 바카라사이트

  32. Pingback: generic vardenafil

  33. Pingback: vardenafil generic

  34. Pingback: best casino online

  35. Pingback: sugarhouse casino online

  36. Pingback: herbal viagra

  37. Pingback: play online casino real money

  38. Pingback: pala casino online

  39. Pingback: buy cialis

  40. Pingback: no credit check loans

  41. Pingback: payday advance

  42. Pingback: quick cash loans

  43. Pingback: viagra cost

  44. Pingback: casinos online

  45. Pingback: generic for cialis

  46. Pingback: adriene

  47. Pingback: online slots

  48. Pingback: online casino olympic

  49. Pingback: cialis generic

  50. Pingback: pala casino online

  51. Pingback: cialis 5 mg

  52. Pingback: cialis 20

  53. Pingback: purchasing cialis online

  54. Pingback: tadalafil online

  55. Pingback: tadalafil liquid

  56. Pingback: casino slot

  57. Pingback: online casino

  58. Pingback: buy cialis online

  59. Pingback: purchase generic viagra online

  60. Pingback: Viagra 50mg pills

  61. Pingback: Viagra 50mg without prescription

  62. Pingback: Viagra 50 mg purchase

  63. Pingback: viagra samples

  64. Pingback: hydroxychloroquine 400 mg buy online

  65. Pingback: Viagra 150 mg nz

  66. Pingback: Viagra 200mg uk

  67. Pingback: cost of Cialis 40 mg

  68. Pingback: 메이저사이트

  69. Pingback: Cialis 20mg australia

  70. Pingback: when to take cialis

  71. Pingback: Cialis 60mg pharmacy

  72. Pingback: Cialis 10 mg tablet

  73. Pingback: Cialis 60mg price

  74. Pingback: viagra without subscription

  75. Pingback: Cialis 40 mg united kingdom

  76. Pingback: order sildenafil 130mg

  77. Pingback: tadalafil 80mg online

  78. Pingback: cheapest furosemide 40mg

  79. Pingback: propecia 1 mg no prescription

  80. Pingback: lexapro 5 mg without a doctor prescription

  81. Pingback: finasteride 1 mg tablets

  82. Pingback: abilify 20 mg otc

  83. Pingback: actos 30 mg without a doctor prescription

  84. Pingback: allegra 180mg online

  85. Pingback: allopurinol 300mg without a doctor prescription

  86. Pingback: amoxicillin 250mg canada

  87. Pingback: cleckleyfloors.com

  88. Pingback: ampicillin 500 mg united states

  89. Pingback: antivert 25mg cost

  90. Pingback: arava 10 mg australia

  91. Pingback: strattera 40mg nz

  92. Pingback: aricept 5mg cost

  93. Pingback: arimidex 1 mg online pharmacy

  94. Pingback: tamoxifen 10mg generic

  95. Pingback: cialis tablet

  96. Pingback: atarax 10mg tablet

  97. Pingback: augmentin 875/125mg for sale

  98. Pingback: order avapro 150 mg

  99. Pingback: baclofen 25 mg cheap

  100. Pingback: Premarin 0,3 mg online pharmacy

  101. Pingback: buspar 10mg pills

  102. Pingback: calcium carbonate 500mg without prescription

  103. Pingback: cardizem over the counter

  104. Pingback: casodex 50mg tablets

  105. Pingback: ceclor australia

  106. Pingback: cheapest plaquenil

  107. Pingback: cheap prednisolone

  108. Pingback: amoxicillin alcohol interaction

  109. Pingback: manufacturers coupons for prescription drugs

  110. Pingback: glimepiride without prescription

  111. Pingback: cefuroxime cheap

  112. Pingback: trazodone prices

  113. Pingback: cheap bisacodyl

  114. Pingback: venlafaxinemg online pharmacy

  115. Pingback: amitriptyline australia

  116. Pingback: permethrin without a prescription

  117. Pingback: erythromycin 250mg uk

  118. Pingback: estradiol canada

  119. Pingback: tamsulosin 0.2mg without a prescription

  120. Pingback: alendronate 70 mg online

  121. Pingback: nitrofurantoin 100mg price

  122. Pingback: where to buy glipizide 5mg

  123. Pingback: hydrochlorothiazide tablets

  124. Pingback: isosorbide generic

  125. Pingback: loperamide 2mg online

  126. Pingback: azathioprine 50mg cheap

  127. Pingback: propranolol 80mg over the counter

  128. Pingback: canada cialis online pharmacy

  129. Pingback: does cvs carry generic cialis

  130. Pingback: how to purchase lamotrigine

  131. Pingback: terbinafine over the counter

  132. Pingback: levothyroxine mcg australia

  133. Pingback: gemfibrozil 300 mg prices

  134. Pingback: metoprolol tablets

  135. Pingback: metoclopramide 10 mg price

  136. Pingback: cialis over the counter south africa

  137. Pingback: hydroxychloroquine buy online india

  138. Pingback: buy plaquenil online canada

  139. Pingback: hydroxychloroquine long term

  140. Pingback: Google

  141. Pingback: male masturbation toys

  142. Pingback: realistic penis sleeve

  143. Pingback: trending News

  144. Pingback: wand vibrators

  145. Pingback: pocket stroker

  146. Pingback: International Hospital Management

  147. Pingback: dudullu escort

  148. Pingback: ben wa beads

  149. Pingback: thrusting rabbit vibrator

  150. Pingback: ivermectil indication

  151. Pingback: best p spot toy

  152. Pingback: sativa for sale online

  153. Pingback: fun88

  154. Pingback: vibrating pocket stroker

  155. Pingback: best prostate massager

  156. Pingback: Best Realistic Masturbator

  157. Pingback: web hosting reviews

  158. Pingback: priligy mexico pharmacy

  159. Pingback: MILF Porn

  160. Pingback: commercial real estate

  161. Pingback: lotto vip

  162. Pingback: ruay สมัครสมาชิก

  163. Pingback: prostate toys

  164. Pingback: best male stroker

  165. Pingback: covered car transport

  166. Pingback: streamcomplet

  167. Pingback: streaming gratuit

  168. Pingback: streaming gratuit

  169. Pingback: jogar online

  170. Pingback: Trade popular cryptocurrency

  171. Pingback: twitter video download

  172. Pingback: pocket vagina

  173. Pingback: ivermectin uses

  174. Pingback: stromectol and potassium

  175. Pingback: best sex toys

  176. Pingback: what is masturbation

  177. Pingback: best vibrating cock ring

  178. Pingback: w88ok

  179. Pingback: vacuum erection device

  180. Pingback: male masturbator review

  181. Pingback: best in ottawa

  182. Pingback: 안전놀이터

  183. Pingback: https://shotgunsforsale.net/product/browning-citori-725-sporting-for-sale/

  184. Pingback: pmang-no1.com

  185. Pingback: russian store

  186. Pingback: Budongo Forest

  187. Pingback: Kingpen

  188. Pingback: herbamedicus

  189. Pingback: big chief blackwater og

  190. Pingback: cockatoo for sale near

  191. Pingback: NAPHYRONE FOR SALE

  192. Pingback: Chihuahua Puppies For Sale near me

  193. Pingback: Pudsey Grangefield Maths and Computing College

  194. Pingback: online pharmacy

  195. Pingback: blow job

  196. Pingback: vibrating dildo

  197. Pingback: projektownie wnętrz Gdynia

  198. Pingback: بديل تروكولر

  199. Pingback: hydroxychloroquine et la grossesse

  200. Pingback: free download for pc windows

  201. Pingback: free download for windows 7

  202. Pingback: laptop app

  203. Pingback: stromectol 6mg

  204. Pingback: pc games for windows 7

  205. Pingback: deltasone a penicillin

  206. Pingback: free download for windows 10

  207. Pingback: pc games for windows xp

  208. Pingback: mp3 player juice

  209. Pingback: download pc games for windows 7

  210. Pingback: Capuchin Monkey For Sale

  211. Pingback: Site internet Wordpress

  212. Pingback: Best Deals On Sig Sauer

  213. Pingback: IT Services Somerset

  214. Pingback: Pinball Machines for Sale

  215. Pingback: Macbook air akku reparatur bubikon

  216. Pingback: How to get to Masai Mara national park

  217. Pingback: Shipping containers For Sale

  218. Pingback: buy ivermectin online no prescription

  219. Pingback: Mac akku auswechseln bubikon

  220. Pingback: Uganda adventure safaris

  221. Pingback: FARMING EQUIPMENT FOR SALE NEAR ME

  222. Pingback: best male sex toys

  223. Pingback: shipping containers for sale

  224. Pingback: Serengeti African safari

  225. Pingback: ارقام بنات

  226. Pingback: aromatherapy oils

  227. Pingback: stromectol price

  228. Pingback: tab ivermectin

  229. Pingback: izrada web sajtova

  230. Pingback: loweslife

  231. Pingback: Buy Adderall XR Capsules online

  232. Pingback: TRIPLE HEX CARTS

  233. Pingback: kimber k6s for sale

  234. Pingback: taurus 92fs stainless

  235. Pingback: mossberg mvp patrol

  236. Pingback: invaders from the planet moolah slot machine for sale

  237. Pingback: buy nembutal online

  238. Pingback: stillzy starter kit

  239. Pingback: magic mushrooms

  240. Pingback: magic mushrooms

  241. Pingback: background check website

  242. Pingback: nuy marijuana online new york

  243. Pingback: juul cartridges

  244. Pingback: armadillo lizard for sale

  245. Pingback: beretta a400 xcel parallel target

  246. Pingback: ROVE CARTS

  247. Pingback: blue recliner

  248. Pingback: exotic cannabis for sale

  249. Pingback: buy crypto mining machines in europe

  250. Pingback: Fennec Fox for Sale Near Me

  251. Pingback: Travelmonke Tours

  252. Pingback: d33006 video card

  253. Pingback: buy hex dumbbells

  254. Pingback: وكالة تسويق

  255. Pingback: Remington Model 700 

  256. Pingback: stock market technical analysis

  257. Pingback: buy ritalin online

  258. Pingback: RissMiner

  259. Pingback: Ashingdon Primary Academy

  260. Pingback: Order Sig Sauer Firearms Online

  261. Pingback: dizziness

  262. Pingback: bitcoin

  263. Pingback: samantha lewes

  264. Pingback: Uganda Tour

  265. Pingback: Gorilla Trekking

  266. Pingback: Kenya Gorilla Trekking

  267. Pingback: beretta guns

  268. Pingback: savage grow

  269. Pingback: raw garden extract cartridges

  270. Pingback: sig sauer handguns

  271. Pingback: ltakside sikin beni

  272. Pingback: realistic male stroker

  273. Pingback: male masturbators

  274. Pingback: BUY DMT ONLINE

  275. Pingback: springfield saint upper

  276. Pingback: Rolex Submariner

  277. Pingback: glo blue dream

  278. Pingback: best pharmacy online

  279. Pingback: buy raw garden cartridges online

  280. Pingback: MURANG'A UNIVERSITY OF TECHNOLOGY

  281. Pingback: happyLuke

  282. Pingback: mint juul pod

  283. Pingback: can i buy sildenafil over the counter in canada

  284. Pingback: Cheap rentals in Montenegro

  285. Pingback: Buy Adderall | Ritalin and Vyvanse Online

  286. Pingback: buy youtube subscribers

  287. Pingback: ebit-e9-pro-25t-s-with-psu-bitcoin-btc-miner-new-for-sale

  288. Pingback: CableFreeTV

  289. Pingback: Gorilla Trekking Bwindi Impenetrable forest

  290. Pingback: happyruck.com

  291. Pingback: Artvin Gazette

  292. Pingback: happyruck

  293. Pingback: virtual card buy with bitcoin

  294. Pingback: russian characters

  295. Pingback: white hennessy for sale near me

  296. Pingback: affiliate millionaire club

  297. Pingback: how to clean black money with vitamin c

  298. Pingback: ruger guns for sale

  299. Pingback: e-cigs for sale in usa

  300. Pingback: top rated solar powered generator

  301. Pingback: best solar panels

  302. Pingback: Army Public SchoolVairengte C/o Cijw School C/o 99 Apo Aizwal Mizoram Mizoram 825325 India

  303. Pingback: S V M Jr College Of Sci & Com Ward No. 1, Palghar - 401208

  304. Pingback: Babasaheb Bhimrao Ambedkar University - Amethi Satellite Campus

  305. Pingback: high school u s a

  306. Pingback: Phentermine 37.5mg for sale

  307. Pingback: jujutsu kaisen

  308. Pingback: sex toys kit

  309. Pingback: walther arms products handguns ppq manuals

  310. Pingback: browning micro midas 20 gauge

  311. Pingback: Daily CBD — The Leading Cannabinoid Educational Resource

  312. Pingback: beretta 85fs cheetah for sale

  313. Pingback: Uganda Safari Holidays

  314. Pingback: buy real driver license

  315. Pingback: reliable nembutal suppliers

  316. Pingback: Buy 1L GBL Cleaner

  317. Pingback: e-cigarettes for sale

  318. Pingback: kimber rifles

  319. Pingback: THC Oil for Sale

  320. Pingback: Slots

  321. Pingback: Kolkata escorts

  322. Pingback: remington tac 13 for sale

  323. Pingback: iwi tavor 308

  324. Pingback: stiiizy pods flavors

  325. Pingback: live resin stiiizy

  326. Pingback: takeout

  327. Pingback: firearms for sale in Europe

  328. Pingback: BEST GUNS FOR SALE

  329. Pingback: taurus g3 for sale

  330. Pingback: uca.com.vn

  331. Pingback: downloas mp3

  332. Pingback: Mr Mushies Psilocybin Swiss Choc Bars – 3g

  333. Pingback: gbl for sale uk

  334. Pingback: buy-gamma-butyrolactone-online

  335. Pingback: order Oxycodone online

  336. Pingback: order Oxycodone online

  337. Pingback: paint sprayer

  338. Pingback: Perdomo Cigars

  339. Pingback: beezle sauce cartridges

  340. Pingback: Последние новости

  341. Pingback: online marketing

  342. Pingback: ruger ec9s purple

  343. Pingback: how to use rechargeable rabbit vibrators

  344. Pingback: big dildo

  345. Pingback: anal butt plug

  346. Pingback: buy genuine driving license

  347. Pingback: divorce lawyers

  348. Pingback: university college in kenya

  349. Pingback: buy polygon t8 frame

  350. Pingback: male masturbator

  351. Pingback: ZOHYDRO ER PRECIO

  352. Pingback: best g spot vibrator

  353. Pingback: vibrator set

  354. Pingback: kel tec 9mm

  355. Pingback: invicta hydromax watch

  356. Pingback: mossberg 930 jm

  357. Pingback: beretta a350

  358. Pingback: krt cart

  359. Pingback: Krt vape

  360. Pingback: crypto mining equipment usa

  361. Pingback: Krt disposable vape

  362. Pingback: gamma labs website

  363. Pingback: Order Herbal Incense Online

  364. Pingback: Hi-Point carbine

  365. Pingback: vibrator

  366. Pingback: adam and eve sex toys

  367. Pingback: Mount Kilimanjaro Trek

  368. Pingback: Cryptocurrency wallet api

  369. Pingback: Buy Marijuana Online

  370. Pingback: sextoys reddit

  371. Pingback: sugar gliders for sale near me

  372. Pingback: Benelli M1 Super 90 for sale

  373. Pingback: buy virtual card with cryptocurrency

  374. Pingback: Scrap Car Removal Richmond

  375. Pingback: refinance your mortgage

  376. Pingback: Glock 28

  377. Pingback: lottovip

  378. Pingback: Colt Python

  379. Pingback: Herbal Incense

  380. Pingback: rechargeable vibrator

  381. Pingback: adam and eve vibrators

  382. Pingback: tiktok video downloader

  383. Pingback: Hk vp9

  384. Pingback: Ps5 for Sale

  385. Pingback: purple 380 pistol

  386. Pingback: crocoite crystal

  387. Pingback: Glock 34 for Sale

  388. Pingback: ball massage handjob

  389. Pingback: kaynarca escort

  390. Pingback: bitcoin visa card

  391. Pingback: butt plug

  392. Pingback: free download for windows pc

  393. Pingback: pc games free download for windows 7

  394. Pingback: free laptop games download

  395. Pingback: pc games for windows 7

  396. Pingback: pc games for windows 7

  397. Pingback: 0xC66D8B9fA986ffA193951ff6E2e122974C42313C

  398. Pingback: free download for pc

  399. Pingback: wasa

  400. Pingback: Ruger sr22 for sale

  401. Pingback: Herbal Incense

  402. Pingback: how to massage your clit using clit suction vibrator

  403. Pingback: masturbation

  404. Pingback: gable boxes

  405. Pingback: Glock 19 for sale

  406. Pingback: Uganda safari vacations

  407. Pingback: marijuana-us.com

  408. Pingback: business in canada

  409. Pingback: Cake carts

  410. Pingback: cash for cars

  411. Pingback: BERETTA 92FS

  412. Pingback: CZ P01

  413. Pingback: penis sleeves

  414. Pingback: Takeout

  415. Pingback: windows doktor meilen

  416. Pingback: understanding stocks

  417. Pingback: carrefour

  418. Pingback: Nursing Homeworks

  419. Pingback: management homework help

  420. Pingback: Buy Research Chemicals Online

  421. Pingback: Google

  422. Pingback: scrap car pick up

  423. Pingback: Payday Loans

  424. Pingback: how to use thrusting rabbit vibrators

  425. Pingback: male pumping device

  426. Pingback: Canada

  427. Pingback: virtual card buy with cryptocurrency

  428. Pingback: Oahidur Islam Roman

  429. Pingback: premature ejection problem solution

  430. Pingback: buy magic mushrooms

  431. Pingback: Pinball machines for sale

  432. Pingback: Watermelon haupia

  433. Pingback: Watermelon haupia

  434. Pingback: Bubble hash

  435. Pingback: Moroccan hash

  436. Pingback: Litto disposable

  437. Pingback: Bubble hash

  438. Pingback: 2dedication

  439. Pingback: 2ungracious

  440. Pingback: University of Embu

  441. Pingback: School of Pure and Applied Sciences Embu University

Leave a Reply