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Gupta M, Grinman M. Diagnostic et prise en charge de l’œsophagite à éosinophiles. CMAJ 2024; 196:E568-E576. [PMID: 38684286 PMCID: PMC11057888 DOI: 10.1503/cmaj.230378-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Milli Gupta
- Divisions de gastroentérologie et d'hépatologie (Gupta) et de médecine interne générale (Grinman), Département de médecine, École de médecine Cumming, Université de Calgary, Calgary, Alb.
| | - Michelle Grinman
- Divisions de gastroentérologie et d'hépatologie (Gupta) et de médecine interne générale (Grinman), Département de médecine, École de médecine Cumming, Université de Calgary, Calgary, Alb
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Nader LS, Epifanio M, Coelho MG, Steinhaus C, Melere M, da Silva CS, Ferreira CT. High prevalence of response to PPI treatment in children and adolescents with eosinophilic esophagitis in southern Brazil. FRONTIERS IN ALLERGY 2024; 5:1346843. [PMID: 38650863 PMCID: PMC11033356 DOI: 10.3389/falgy.2024.1346843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction Eosinophilic esophagitis is a newly recognized entity, in which there is significant evidence available that clearly demonstrates the positive impact of PPIs on reducing esophageal eosinophilia in individuals across different age groups, including children, adolescents, and adults. Multiple mechanisms have been proposed to explain how this treatment effect occurs. In Brazil, there seems to be a lack of studies that have prospectively assessed the clinical and therapeutic response rate in pediatric patients with EoE. The objective of this study was to prospectively evaluate the clinical and therapeutic response of pediatric patients with EoE in a medical center located in southern Brazil, by investigating the effectiveness of PPI treatment. Methods This study is a clinical, prospective, open trial that took place in a pediatric hospital located in southern Brazil. The focus of the study was on patients diagnosed with Eosinophilic Esophagitis (EoE) who were given treatment using omeprazole/esomeprazole at a dosage of 1 mg.kg per dose, twice daily, for a period of 8-12 weeks. Following the treatment period, the patients underwent another endoscopy. Patients who exhibited 15 or less eosinophils in the biopsy conducted after the treatment were considered as responders. Results A total of 27 patients was evaluated (74.1% boys). The average age (± standard deviation) was 8 years (±4). Nineteen patients (70.3%) were considered as responders to PPI treatment: 6 patients-22.2%-exhibited a complete response (defined as having 5 or fewer eosinophil per high power field. Additionally, 13 patients-48.1%-demonstrated a partial response, characterized by eosinophil counts exceeding 5 but less than 15 eos/hpf. When comparing the responder and non-responder groups at presentation, a statistical difference was observed in the prevalence of food refusal as a presenting symptom. Food refusal was found to be more prevalent in the non-responder group (87.5% vs. 26.3%, P = 0.008). No differences were observed in terms of atopy history and endoscopic scores. Upon comparing the histological findings from the post-treatment endoscopy of the two groups, it was observed that PPI responders exhibited a greater tendency to decrease basal cell hyperplasia (P = 0.06) and intercellular edema (P = 0.08). Conclusion In this group of pediatric patients with EoE in Southern Brazil most patients showed a high prevalence of histological, endoscopic, and clinical response to PPI treatment. PPIs showed efficacy in Brazilian patients with EoE, most of whom would probably not be able to adequately undergo other treatments. Clinical Trial Registration https://ensaiosclinicos.gov.br/rg/RBR-2ntbth9, identifier (U1111-1301-1842).
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Affiliation(s)
- Luiza Salgado Nader
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Matias Epifanio
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Cintia Steinhaus
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Melina Melere
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Carolina Soares da Silva
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Cristina Targa Ferreira
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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Gupta M, Grinman M. Diagnosis and management of eosinophilic esophagitis. CMAJ 2024; 196:E121-E128. [PMID: 38316452 PMCID: PMC10843442 DOI: 10.1503/cmaj.230378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Affiliation(s)
- Milli Gupta
- Divisions of Gastroenterology and Hepatology (Gupta), and General Internal Medicine (Grinman), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.
| | - Michelle Grinman
- Divisions of Gastroenterology and Hepatology (Gupta), and General Internal Medicine (Grinman), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta
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Massironi S, Elvevi A, Panceri R, Mulinacci G, Colella G, Biondi A, Invernizzi P, Danese S, Vespa E. Eosinophilic esophagitis: does age matter? Expert Rev Clin Immunol 2024; 20:211-223. [PMID: 37870118 DOI: 10.1080/1744666x.2023.2274940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus with increasing prevalence worldwide. It is a multifactorial disease caused by a combination of immunologic, genetic, and environmental factors. The clinical presentation of EoE varies largely, especially between different age groups. While diagnostic criteria and therapeutic goals are similar in children and adults, there are differences in treatment, with a more cautious approach in children to avoid growth disturbances. In addition, close monitoring and follow-up are essential in children to ensure uninterrupted growth. AREAS COVERED A search in PubMed/MEDLINE, EMBASE, and SCOPUS databases was conducted to identify relevant studies published between January 2010 and January 2023 to give an overview of the state-of-the-art of EoE epidemiology, diagnosis, and treatment while focusing on similarities and differences between the adult and the pediatric population. EXPERT OPINION The current state of research indicates that while significant progress has been made in understanding and treating EoE, further research and advances are needed to optimize diagnostic strategies, tailored treatment approaches, monitoring, and follow-up, and improve long-term outcomes for patients. With further innovation, the management of EoE can become more precise and tailored, leading to better patient outcomes and improved quality of life.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Roberto Panceri
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Giacomo Mulinacci
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giacomo Colella
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Andrea Biondi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Pietro Invernizzi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
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5
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Sharlin CS, Mukkada VA, Putnam PE, Bolton SM. Treatment of Pediatric Eosinophilic Esophagitis: Traditional and Novel Therapies. Curr Gastroenterol Rep 2023; 25:289-298. [PMID: 37658151 DOI: 10.1007/s11894-023-00893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE OF REVIEW This review presents and summarizes the existing studies on the treatment goals and options for pediatric eosinophilic esophagitis utilizing rigorous peer-reviewed literature. RECENT FINDINGS In addition to traditional treatments, emerging biologic therapies continue to evolve the approach to treating pediatric eosinophilic esophagitis. Well defined treatment goals will aid the continued development of new therapies. Further, innovative assessment tools have changed how the clinician is able to assess the effectiveness of therapies with a trend toward less invasive options. The management of pediatric eosinophilic esophagitis continues to evolve with the advent of both novel treatment options and assessment tools. Treatment choices, with benefits and risks involved, should be presented to families upon diagnosis and tailored towards the individual patient and likelihood of adherence and success. Biologic therapy for EoE presents an exciting option for both first line therapy and escalation for those with severe or unresponsive disease.
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Affiliation(s)
- Colby S Sharlin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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Nguyen N, Burger C, Skirka S, White S, Smith M, Menard-Katcher C, Furuta GT, Mehta P. One Year Into Dupilumab: Physician and Patient Experiences in Initiating Dupilumab for Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 77:536-539. [PMID: 37491718 DOI: 10.1097/mpg.0000000000003901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
In 2022, the US Food and Drug Administration approved dupilumab for treatment of eosinophilic esophagitis (EoE). The aims of this study were to report physician and patient perspectives on initiating dupilumab. A 2-pronged approach was used: (1) data on physician prescribing practices was gathered via retrospective chart review of EoE patients prescribed dupilumab and (2) pediatric patients on dupilumab were approached to complete a questionnaire regarding reasons for initiation. During this time, 42 patients were prescribed dupilumab. From the physician's perspective, the primary reasons for dupilumab included nonresponse to topical corticosteroids (TCS) (52%), nonadherence (28%), adverse effects (10%), or to treat multiple atopic diseases (5%). The median dupilumab initiation time, from day prescribed to first injection, was 37 days [interquartile range (IQR) 37]. Almost all required prior authorization (PA) (98%), while 17% required letter of appeal and 2% required peer-to-peer. Fifteen patients (36%) completed the questionnaire portion of the study. From the patient's perspective, the primary reasons for dupilumab initiation included nonresponse to TCS (27%), nonadherence to TCS (27%), concern about adverse effects of TCS (7%), and treatment of multiple atopic diseases (33%). In conclusion, physicians are prescribing dupilumab primarily for nonresponse to TCS and almost all required PA with a long delay to starting dupilumab.
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Affiliation(s)
- Nathalie Nguyen
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cassandra Burger
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Stephanie Skirka
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Shannon White
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Melanie Smith
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Calies Menard-Katcher
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Glenn T Furuta
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Pooja Mehta
- From the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO
- the Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Nistel M, Furuta GT, Pan Z, Hsu S. Impact of Dose Reduction of Topical Steroids to Manage Adrenal Insufficiency in Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 76:786-792. [PMID: 36306502 PMCID: PMC10147844 DOI: 10.1097/mpg.0000000000003647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the impact of type and dose of swallowed topical steroids (STS) and concurrent steroid therapy on the development and resolution of adrenal insufficiency (AI) in pediatric eosinophilic esophagitis (EoE). METHODS We performed a retrospective case-control study of pediatric EoE subjects in a single tertiary care center, who were treated with STS for at least 3 months and diagnosed with AI based on a peak stimulated cortisol level of <18 µg/dL (500 nmol/L). Steroid forms and doses, and endoscopy data were collected at the time of AI diagnosis and AI resolution or the last known evaluation. Steroid formulations were converted to a fluticasone-equivalent dose for analysis. RESULTS Thirty-two EoE subjects with AI were identified, and 20 had AI resolution, including 12 who remained on lower dose STS. Eight of the 32 patients were also treated with extended-release budesonide (ER budesonide), which resulted in a 7-fold higher total daily steroid dose, and thus were analyzed separately. When the 24 cases that were not on ER budesonide were compared to the 81 controls, no difference was found in the STS dose nor total daily steroid dose, although the inhaled steroid dose had marginal significance. Peak eosinophil counts tended to increase when STS doses were decreased, except in subjects on ER budesonide at AI diagnosis. CONCLUSION Altering the total daily steroid regimen can lead to resolution of AI in patients with EoE, though this may come at the expense of disease control.
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Affiliation(s)
- Mason Nistel
- Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
| | - Zhaoxing Pan
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
- Biostatistics Core of the Children’s Hospital Colorado Research Institute, Aurora, CO
| | - Stephanie Hsu
- Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO
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Sindher SB, Barshow S, Tirumalasetty J, Arasi S, Atkins D, Bauer M, Bégin P, Collins MH, Deschildre A, Doyle AD, Fiocchi A, Furuta GT, Garcia-Lloret M, Mennini M, Rothenberg ME, Spergel JM, Wang J, Wood RA, Wright BL, Zuberbier T, Chin AR, Long A, Nadeau KC, Chinthrajah RS. The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders. J Allergy Clin Immunol 2023; 151:595-606. [PMID: 36872039 PMCID: PMC9993424 DOI: 10.1016/j.jaci.2023.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Abstract
Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.
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Affiliation(s)
- Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Suzanne Barshow
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Jyothi Tirumalasetty
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Stefania Arasi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dan Atkins
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maureen Bauer
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Philippe Bégin
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Antoine Deschildre
- CHU Lille, Université Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Lille, France
| | - Alfred D Doyle
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Glenn T Furuta
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maria Garcia-Lloret
- Department of Pediatrics, Division of Immunology, Allergy, and Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Maurizio Mennini
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - Robert A Wood
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Torsten Zuberbier
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Andrew R Chin
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif.
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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10
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Schor B, Blanco P, Rivera-Nieves D, Wilsey M, Karjoo S. Esophageal polyp in a teenage boy with eosinophilic esophagitis. SAGE Open Med Case Rep 2022; 10:2050313X221116954. [PMID: 35991956 PMCID: PMC9382070 DOI: 10.1177/2050313x221116954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 07/14/2022] [Indexed: 11/19/2022] Open
Abstract
The association of eosinophilic esophagitis and esophageal polyps has been
reported in the literature but remains a rare finding in both adults and
children. The patient in this case report presented with progressively worsening
dysphagia secondary to eosinophilic esophagitis and an esophageal polyp.
Dysphagia is always abnormal, and endoscopic evaluation is essential. Dysphagia
is a well-known symptom in patients with eosinophilic esophagitis. While
esophageal polyps as a whole are less common in the pediatric population, they
should not be overlooked as a possible cause of dysphagia and esophageal
obstruction.
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Affiliation(s)
- Berni Schor
- Department of Pediatrics, Columbia University, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY, USA
| | - Paola Blanco
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Desiree Rivera-Nieves
- Department of Pediatric Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Michael Wilsey
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Pediatric Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Sara Karjoo
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Pediatric Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- College of Medicine, Florida State University, Tallahassee, FL, USA
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11
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Fernandez-Becker NQ. Eosinophilic Esophagitis: Incidence, Diagnosis, Management, and Future Directions. Gastroenterol Clin North Am 2021; 50:825-841. [PMID: 34717873 DOI: 10.1016/j.gtc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Eosinophilic esophagitis (EoE) is an antigen-mediated esophageal disease defined by the presence of esophageal eosinophilia and symptoms of esophageal dysfunction. The pathophysiology involves an allergen-driven Th2 T cell response that triggers infiltration of eosinophils into the esophagus leading to inflammation, remodeling, and fibrosis. This results in disruption of esophageal function and accompanying symptoms - most notably dysphagia. Effective therapies target inflammation or fibrostenotic complications and include proton pump inhibitors, swallowed topical steroids, dietary exclusion, and dilation. Clinical trials testing promising biologic therapies are ongoing.
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Barni S, Arasi S, Mastrorilli C, Pecoraro L, Giovannini M, Mori F, Liotti L, Saretta F, Castagnoli R, Caminiti L, Cianferoni A, Novembre E. Pediatric eosinophilic esophagitis: a review for the clinician. Ital J Pediatr 2021; 47:230. [PMID: 34809686 PMCID: PMC8609874 DOI: 10.1186/s13052-021-01178-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Stefania Arasi
- Predictive and Preventive Medicine Research Unit, Multifactorial and Systemic Diseases Research Area, Pediatric Allergy Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Pecoraro
- Department of Medicine, University of Verona, Policlinico GB Rossi, Verona, Italy
- Pediatric Unit, ASST Mantua, Mantua, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Senigallia Hospital, Senigallia, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Antonella Cianferoni
- Pediatrics Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Allergy and Immunology Division, The Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
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Nistel M, Nguyen N, Atkins D, Miyazawa H, Burger C, Furuta GT, Menard-Katcher C. Ciclesonide Impacts Clinicopathological Features of Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4069-4074. [PMID: 34293498 DOI: 10.1016/j.jaip.2021.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic allergen-mediated disease of the esophagus. Pharmacologic treatment has largely relied on repurposing corticosteroids. Ciclesonide (CIC) is a corticosteroid for the treatment of asthma with biochemical properties that improve topical potency. OBJECTIVE To determine whether CIC decreased clinicopathological features of EoE. METHODS We performed a retrospective cohort study of patients with EoE treated with CIC at a pediatric hospital from 2010 to 2019. Data were extracted from the electronic health record. Patients who were prescribed CIC with pre- and post-CIC endoscopic and histological data available were included for analysis. RESULTS A total of 281 patients were treated with CIC and 81 met criteria for inclusion. Use of CIC was associated with reduced symptoms including dysphagia (P < .001), abdominal pain (P < .001), vomiting (P = .01), heartburn (P = .02), and behavior changes (P = .02). Average composite endoscopic reference scores decreased from 2.54 to 1.37 (P < .001), with improvement in exudates, edema, and furrows (all P < .001). Peak eosinophil counts decreased from 48 to 23 eosinophils/hpf (P < .001). Forty-three patients (53%) achieved remission (<15 eosinophils/hpf). Esophageal Candida was reported in 1 patient. Fasting morning cortisol concentrations were low in 10 of 31 patients tested. Six of these 10 patients had abnormal adrenocorticotropic hormone stimulation testing, 5 of 6 diagnosed with adrenal insufficiency before transition to CIC and 3 of 6 with subsequent normalization of adrenal function on CIC therapy. CONCLUSIONS Patients with EoE treated with CIC experienced significant reductions in clinicopathological features of EoE. CIC can be considered an alternative therapy in patients with known adrenal insufficiency or at risk of developing adrenal insufficiency.
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Affiliation(s)
- Mason Nistel
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nathalie Nguyen
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Dan Atkins
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Heather Miyazawa
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Cassandra Burger
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Calies Menard-Katcher
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colo; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
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14
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Kochis SR, Cooke DW, Dantzer J, Wood R, Keet C. Low detection of adrenal suppression secondary to swallowed steroids for eosinophilic esophagitis in a quality improvement project. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:3647-3649.e3. [PMID: 32668294 PMCID: PMC7655671 DOI: 10.1016/j.jaip.2020.06.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/30/2020] [Accepted: 06/16/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Suzanne R Kochis
- Division of Pediatric Allergy/Immunology, Johns Hopkins School of Medicine, Baltimore, Md.
| | - David W Cooke
- Division of Pediatric Endocrinology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Jennifer Dantzer
- Division of Pediatric Allergy/Immunology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Robert Wood
- Division of Pediatric Allergy/Immunology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Corinne Keet
- Division of Pediatric Allergy/Immunology, Johns Hopkins School of Medicine, Baltimore, Md
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15
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Reddy A, Ashat D, Murali AR. Recent insights on the use of topical steroids in eosinophilic esophagitis. Expert Rev Gastroenterol Hepatol 2020; 14:953-963. [PMID: 32567417 DOI: 10.1080/17474124.2020.1785869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Eosinophilic Esophagitis (EoE) is an immune-mediated, chronic inflammatory disorder of the esophagus. Topical steroids have been used in the management of EoE for over 15 years. However, there are no Food and Drug Administration (FDA) approved drug therapies for EoE. AREAS COVERED This review discusses the current understanding of EoE and the role of topical steroids in the induction and maintenance of remission in patients with EoE. We performed a comprehensive review of the literature, summarized randomized control trials from 2006 to 2020, and provided a simplified management algorithm for EoE. EXPERT OPINION In patients with EoE, topical steroids are effective in inducing clinical and histologic remission. Formulations of topical steroids that maximize the exposure to esophageal mucosa have the highest efficacy. A majority of patients who achieve remission with topical steroids develop clinical and histologic relapse off therapy within a year. Current evidence suggests that maintenance therapy with long-term topical steroids decreases the risk of relapse and progression to fibrostenotic disease. While uncertainty over the dose and duration of maintenance topical steroids and their potential side effects exists, long-term maintenance therapy with topical steroids appears to be the way forward to improve long-term outcomes in patients with EoE.
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Affiliation(s)
- Aditi Reddy
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
| | - Divya Ashat
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA.,Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
| | - Arvind R Murali
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA.,Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
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16
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Fernandez-Becker NQ, Raja S, Scarpignato C, Lynch KL, Ahuja NK, Horsley-Silva JL. Eosinophilic esophagitis: updates on key unanswered questions. Ann N Y Acad Sci 2020; 1481:30-42. [PMID: 32762154 DOI: 10.1111/nyas.14421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/25/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic disease characterized by symptoms of esophageal dysfunction and esophageal eosinophilia. In the last decade, there has been a dramatic increase in its prevalence for reasons that are not completely understood. The underlying pathophysiology involves an antigen-mediated TH 2 immune response that draws eosinophils to the esophagus, causing mucosal inflammation, esophageal remodeling, and fibrosis. This ultimately leads to esophageal dysfunction that most commonly manifests as dysphagia. In this review, we will discuss updates on key questions regarding the diagnosis and treatment of EoE.
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Affiliation(s)
| | - Shreya Raja
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Kristle L Lynch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Chawla K, Alabbas B, Sheth D, Papademetriou M. As Easy as EoE: A Novel and Effective Multidisciplinary Approach to Care of Patients with Eosinophilic Esophagitis in the Age of Biologics. Dig Dis Sci 2020; 65:2196-2202. [PMID: 32519139 DOI: 10.1007/s10620-020-06366-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Karan Chawla
- Department of Internal Medicine, The George Washington University Hospital, Washington, DC, 20037, USA
| | - Bedoor Alabbas
- Division of Hepatology and Gastroenterology, The George Washington University Hospital, Washington, DC, 20037, USA
| | - Dipa Sheth
- Department of Allergy and Immunology, Washington DC Veterans Affairs Medical Center, Washington, DC, 20422, USA
- The George Washington University Hospital, Washington, DC, USA
| | - Marianna Papademetriou
- The George Washington University Hospital, Washington, DC, USA.
- Department of Gastroenterology, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC, 20422, USA.
- Georgetown University Medical Center, Washington, DC, USA.
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18
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Slack IF, Schwartz JT, Mukkada VA, Hottinger S, Abonia JP. Eosinophilic Esophagitis: Existing and Upcoming Therapies in an Age of Emerging Molecular and Personalized Medicine. Curr Allergy Asthma Rep 2020; 20:30. [PMID: 32506181 DOI: 10.1007/s11882-020-00928-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Recent research efforts have spurred great progress in the diagnosis and management of eosinophilic esophagitis (EoE). Nonetheless, challenges remain in addressing disease burden and impairment in the growing EoE population. We highlight work from the Cincinnati Center for Eosinophilic Disorders, the Consortium of Eosinophilic Gastrointestinal Disease Researchers, and others that address these ongoing challenges. RECENT FINDINGS New tools for characterizing EoE disease activity include the EoE Histology Scoring System (EoEHSS), endoscopic alternatives, validated patient-reported outcome (PRO) questionnaires, and investigational biomarkers. These diagnostic and monitoring strategies have been complemented by advances in EoE therapy. Treatment modalities have refined the traditional approaches of dietary elimination, swallowed steroids, and proton pump inhibitors (PPI), and biologics offer promise for future treatment. This review summarizes EoE advances in disease management and newly defined EoE endotypes that may serve as the foundation for EoE-personalized medicine.
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Affiliation(s)
- Ian F Slack
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - Justin T Schwartz
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shawna Hottinger
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA.
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19
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Abstract
Eosinophilic esophagitis (EoE) is a relatively new disease that has reached an incidence similar to that of Crohn disease and ulcerative colitis. With this increased presence, greater recognition is essential. This applies both to children with nonspecific but potentially debilitating symptoms and to adults who have spent years behaviorally compensating for narrow esophageal strictures. The pathogenesis of EoE is rapidly being unraveled and is based on initiation of a type II allergic response to specific food antigens, leading to dense esophageal eosinophilia, chronic inflammation, and esophageal fibrosis. With greater familiarity and understanding of EoE, treatments are evolving, including identification and avoidance of food antigens; broad applications of topical steroids; and, eventually, pathway-specific biologic therapy.
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20
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Rustagi S, Mullins D, Yanney E. Current updates in diagnosis and management of eosinophilic esophagitis. Curr Probl Pediatr Adolesc Health Care 2020; 50:100783. [PMID: 32446911 DOI: 10.1016/j.cppeds.2020.100783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis is a relatively new, moderately-well understood disease. It is one of the leading causes of dysphagia in the pediatric population. Thought to be triggered by food ingestion, it is distinctly different from food allergies. Although endoscopy is required for diagnosis, this article will review warning signs and symptoms that aid with evaluation and diagnosis of this disease. Treatment modalities and management are evolving and more research is needed.
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Affiliation(s)
- Shelly Rustagi
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States; Boonshoft School of Medicine, Wright State University, Dayton, OH, United States.
| | - Denise Mullins
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States
| | - Erica Yanney
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States
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21
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Hirano I, Safroneeva E, Roumet MC, Comer GM, Eagle G, Schoepfer A, Falk GW. Editorial: fluticasone propionate orally disintegrating tablets-interesting concept but is it going anywhere? Authors' reply. Aliment Pharmacol Ther 2020; 51:990-991. [PMID: 32338781 DOI: 10.1111/apt.15713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Ikuo Hirano
- Department of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marie C Roumet
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | | | - Gina Eagle
- Adare Pharmaceuticals, Lawrenceville, NJ, USA
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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22
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Adrenal Insufficiency in Children With Eosinophilic Esophagitis Treated With Topical Corticosteroids. J Pediatr Gastroenterol Nutr 2020; 70:324-329. [PMID: 31688699 DOI: 10.1097/mpg.0000000000002537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to identify practices of gastroenterologists screening for adrenal insufficiency (AI) and report prevalence of AI in children with eosinophilic esophagitis (EoE) treated with topical corticosteroids (TCS); compare serum dehydroepiandrosterone sulfate (DHEA-S) levels to morning serum cortisol (MSC) levels as screening tool for AI. METHODS A multipart study was conducted. In part 1, a survey about screening practices for AI in children with EoE on TCS was sent to gastroenterologists belonging to a PedsGI listserv and to EoE consortia. In part 2, children with EoE on TCS for ≥6 months were prospectively screened for AI with MSC levels. For subjects with a MSC level of <10 μg/dL, a repeat MSC level and/or confirmatory adrenocorticotropic hormone (ACTH) stimulation testing was offered. AI was defined by peak serum cortisol level <18 μg/dL. In part 3, DHEA-S levels were drawn with MSC levels. RESULTS Seven percent (16/238) of gastroenterologists screened for AI. Providers in EoE consortia were more likely to screen than nonconsortia providers [9/21(43%) vs 7/217(3%); P = 0.0001]. Thirty-seven children were prospectively screened for AI, and 51% (19/37) had a low MSC level. Ten patients had a low-dose ACTH stimulation test (LDST) after 1 or more low MSC levels. Five percent (2/37) of patients were diagnosed with AI. DHEA-S and MSC levels had a moderate correlation (rs = 0.44, P = 0.03). CONCLUSIONS Gastroenterologists belonging to EoE consortia were more likely to screen for AI. Prevalence of AI in our prospective cohort was 5%. DHEA-S has a moderate correlation with MSC levels, but more data is required to assess utility as a screening tool for AI.
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23
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Lucendo AJ. Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies. Expert Rev Clin Immunol 2020; 16:63-77. [PMID: 31842634 DOI: 10.1080/1744666x.2019.1705784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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24
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Abstract
Food allergies, defined as an immune response to food proteins, affect as many as 8% of young children and 2% of adults in western countries, and their prevalence appears to be rising like all allergic diseases. In addition to well-recognized urticaria and anaphylaxis triggered by IgE antibody- mediated immune responses, there is an increasing recognition of cell-mediated disorders, such as eosinophilic esophagitis and food protein-induced enterocolitis. Non-IgE-Mediated gastrointestinal food allergies are a heterogeneous group of food allergies in which there is an immune reaction against food but the primary pathogenesis is not a production of IgE and activation of mast cells and basophils. Those diseases tend to affect mainly the gastrointestinal tract and can present as acute (FPIES) or chronic reaction, such as Eosinophilic Esophagitis (EoE), Food Protein-Induced Allergic Proctocolitis (FPIAP). The role of food allergy in Non-EoE gastrointestinal Eosinophilic disorders (Non- EoE EGID) is poorly understood. In some diseases like EoE, T cell seems to play a major role in initiating the immunological reaction against food, however, in FPIES and FPIAP, the mechanism of sensitization is not clear. Diagnosis requires food challenges and/or endoscopies in most of the patients, as there are no validated biomarkers that can be used for monitoring or diagnosis of Non-IgE mediated food allergies. The treatment of Non-IgE food allergy is dependent on diet (FPIES, and EoE) and/or use of drugs (i.e. steroids, PPI) in EoE and Non-EoE EGID. Non-IgE mediated food allergies are being being investigated.
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Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
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25
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Diagnostic and Therapeutic Long-term Management of Eosinophilic Esophagitis- Current Concepts and Perspectives for Steroid Use. Clin Transl Gastroenterol 2019; 9:e212. [PMID: 30802222 PMCID: PMC6303250 DOI: 10.1038/s41424-018-0074-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus, which requires short- and long-term treatment. In addition, patients under long-term treatment for any chronic condition should have a structured follow-up. The mainstays in EoE treatment are drugs (such as swallowed topical corticosteroids [STC] and proton pump inhibitors), dietary exclusions, and endoscopic dilations. STC are the most widely used treatment and have proven efficacy in inducing clinical, endoscopic and histological remission in active EoE. However, data regarding maintaining disease remission and long-term management are limited. Ongoing disease activity and relapses despite STC treatment are frequently observed. This sheds light on the urgent need for adequate maintenance strategies, which have not been well defined. In terms of follow-up concepts, to date neither guidelines nor consensus recommendations have been published. To summarize the current knowledge on long-term diagnostic and therapeutic STC management of EoE, we conducted a literature search using PubMed and Embase applying the following key search items: Eosinophilic esophagitis, eosinophils, esophagus, swallowed topical corticosteroids, fluticasone, budesonide, long-term, treatment, therapy, and follow-up. In addition, we present empirically developed long-term management concepts applied at two large EoE centers, with a special focus on STC treatments. Finally, we highlight areas of future research and perspectives regarding the long-term management of EoE.
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26
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Gómez-Aldana A, Jaramillo-Santos M, Delgado A, Jaramillo C, Lúquez-Mindiola A. Eosinophilic esophagitis: Current concepts in diagnosis and treatment. World J Gastroenterol 2019; 25:4598-4613. [PMID: 31528089 PMCID: PMC6718043 DOI: 10.3748/wjg.v25.i32.4598] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/13/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis is an immune-allergic pathology of multifactorial etiology (genetic and environmental) that affects both pediatric and adult patients. Its symptoms, which include heartburn, regurgitation, and esophageal stenosis (with dysphagia being more frequent in eosinophilic esophagitis in young adults and children), are similar to those of gastroesophageal reflux disease, causing delays in diagnosis and treatment. Although endoscopic findings such as furrows, esophageal mucosa trachealization, and whitish exudates may suggest its presence, this diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated. Currently, the 3 “D”s (“Drugs, Diet, and Dilation”) are considered the fundamental components of treatment. The first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for esophageal strictures. Herein, the most important aspects of eosinophilic esophagitis pathophysiology will be reviewed, in addition to evidence for the various treatments.
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Affiliation(s)
- Andrés Gómez-Aldana
- Departament of Internal Medicine, Section of Gastroenterology, Santa Fe Foundation of Bogotá (Fundación Santa Fe de Bogotá), Bogotá 220246, Colombia
- University of Los Andes, Bogotá 111711, Colombia
| | - Mario Jaramillo-Santos
- Department of Endoscopy, Caldas University, Manizales 275, Colombia
- Department of Endoscopy, Surgeons’ Union SAS (Joint stock company) (Union de cirujanos SAS), Manizales 170001661, Colombia
| | - Andrés Delgado
- Departament of Internal Medicine, Section of Gastroenterology, Santa Fe Foundation of Bogotá (Fundación Santa Fe de Bogotá), Bogotá 220246, Colombia
| | - Carlos Jaramillo
- Department of Endoscopy, Caldas University, Manizales 275, Colombia
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Zheng P, Tan HY. New developments in diagnosis and treatment of eosinophilic esophagitis. Shijie Huaren Xiaohua Zazhi 2019; 27:828-834. [DOI: 10.11569/wcjd.v27.i13.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune mediated disease of the esophagus that progresses to esophageal fibrostenosis if not well treated. The aim of this review is to provide an update on recent clinical advances in the development of diagnostic and therapeutic approaches for EoE. At present, the diagnosis and disease monitoring for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include transnasal endoscopy, endoscopic functional lumen imaging probe, and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. The current treatment modalities for EoE are topical corticosteroid, proton-pump inhibitors, elimination diet, and dilation. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab. Especially, dupilumab is promising to become the orphan drug of EoE.
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Affiliation(s)
- Pu Zheng
- Department of Emergency Medicine, Beijing Hospital, Beijing 100005, China
| | - Huang-Ying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing 100029, China
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Rodríguez Manchón S, Domínguez Ortega G, Bacelo Ruano I, Martínez Ibeas MA, Pozo Román J, Cañedo Villarroya E, Muñoz Codoceo RA. Letter: reassuringly normal response to ACTH in children treated with swallowed topical corticosteroids for eosinophilic oesophagitis. Aliment Pharmacol Ther 2019; 49:1537-1538. [PMID: 31134648 DOI: 10.1111/apt.15243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Silvia Rodríguez Manchón
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Gloria Domínguez Ortega
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Irene Bacelo Ruano
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - María Angeles Martínez Ibeas
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jesús Pozo Román
- Paediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Elvira Cañedo Villarroya
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Rosa Ana Muñoz Codoceo
- Department of Paediatrics, Section of Gastroenterology and Nutrition, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Safety and Efficacy of Budesonide Oral Suspension Maintenance Therapy in Patients With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:666-673.e8. [PMID: 29902649 DOI: 10.1016/j.cgh.2018.05.051] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/17/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We aimed to determine the safety and efficacy of budesonide oral suspension (BOS) maintenance therapy in patients with eosinophilic esophagitis (EoE). METHODS We performed an open-label extension study of a 12-week, multicenter, randomized, double-blind, placebo-controlled trial. Patients with EoE (11-40 years old) who completed double-blind BOS (n = 45) or placebo therapy (n = 37) received 24 weeks' open-label BOS (2.0 mg once daily for 12 weeks, with optional dose increase [1.5-2.0 mg twice daily] for 12 weeks thereafter). Predefined efficacy outcomes included: proportion of patients with a histologic response (≤6 eosinophils/high-power field [eos/hpf]) and change in mean peak eosinophil counts after 24 weeks. Analyses were stratified by patients who received placebo (placebo/BOS) or BOS (BOS/BOS) during the double-blind trial. RESULTS BOS was well tolerated and drug-related adverse events were uncommon (placebo/BOS, 19% [7/37]; BOS/BOS, 4% [2/45]). Incidence of oral candidiasis (1 per group) and esophageal candidiasis (placebo/BOS group, n = 4) remained low. Changes in morning serum cortisol levels were not clinically relevant. A histologic response was observed in 49% (16/33) of patients receiving placebo/BOS and 23% (9/39) receiving BOS/BOS. Mean peak eosinophil counts (baseline vs week 24 or early termination) were: placebo/BOS, 118.8 vs 29.1; P < .001 and BOS/BOS, 38.1 vs 72.4; P = .01. Of the patients who responded to double-blind therapy, 42% maintained a histologic response during the open-label extension; 4% of nonresponders gained response. CONCLUSIONS In an open-label extension study of patients with EoE, BOS was well tolerated and drug-related adverse events were uncommon. BOS maintained a histologic response in some initial responders, but few initial nonresponders had a response. ClinicalTrials.gov no: NCT01642212.
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Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE. RECENT FINDINGS Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.
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Oliva S, Rossetti D, Papoff P, Tiberti A, Mallardo S, Volpe D, Ruggiero C, Russo G, Vezzoli D, Isoldi S, Cucchiara S. A 12-Week Maintenance Therapy with a New Prepared Viscous Budesonide in Pediatric Eosinophilic Esophagitis. Dig Dis Sci 2019; 64:1571-1578. [PMID: 30659470 PMCID: PMC6522447 DOI: 10.1007/s10620-018-5449-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 12/29/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND A new prepared oral viscous budesonide (PVB) has been effective in inducing clinical and histological remission in pediatric eosinophilic esophagitis (EoE). AIMS To evaluate the efficacy of a 12-week maintenance therapy on clinical, endoscopic, and histological remission using half of the dose used in the induction therapy. METHODS We prospectively enrolled pediatric patients with active EoE. After 12 weeks of induction therapy with PVB (< 150 cm: 2 mg/day; ≥ 150 cm: 4 mg/day) patients received a maintenance dose of half of the dose used in the induction therapy (1 mg or 2 mg) for another 12 weeks. A 12-week follow-up was then performed in all patients after the end of therapy. Endoscopy was performed at weeks 0, 12, 24, and 36. Symptoms, endoscopy, and histology scores were also calculated. Serum cortisol was evaluated during the treatment period. RESULTS We enrolled 20 children (15 males; median age 10 years; range 4-17). After the 12-week induction therapy 18 patients (90%) were in remission, with a significant decrease in the median peak of eosinophil count/HPF as well as a marked reduction in clinical, endoscopic, and histological scores (p < 0.01). At the end of the maintenance therapy (week 24), 17 patients (85%) were still in remission, while there were only 9 at week 36 (45%). No significant changes in cortisol levels were observed during the study period. CONCLUSIONS The 12-week maintenance treatment with the half the dose of PVB was effective in sustaining remission at week 24; however, no reduction in the rate of relapse after suspension of treatment occurred.
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Affiliation(s)
- Salvatore Oliva
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Danilo Rossetti
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Paola Papoff
- Department of Paediatrics, PICU, Sapienza University of Rome, 00161 Rome, Italy
| | - Antonio Tiberti
- Department of Radiological Sciences, Oncology, and Anatomical Pathology, Sapienza – University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Danila Volpe
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Cosimo Ruggiero
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Giusy Russo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Debora Vezzoli
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Sara Isoldi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Salvatore Cucchiara
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Practice Differences in the Diagnosis and Management of Eosinophilic Esophagitis Among Adult and Pediatric Gastroenterologists in Israel. J Pediatr Gastroenterol Nutr 2018; 67:34-39. [PMID: 29394215 DOI: 10.1097/mpg.0000000000001909] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) guidelines call for similar practices in adults and children with EoE. We compared the diagnostic and management practices of gastroenterologists treating adult and pediatric patients suspected of having, or diagnosed with, EoE. METHODS A 19-question multiple-choice questionnaire was given to gastroenterologists treating either adults or children. Questions explored 4 areas of interest: physician demographics, diagnosis and tissue sampling practices, management, and the need for societal publications on EoE. RESULTS Completed questionnaires were returned by 85/180 adult and 30/40 pediatric gastroenterologists (PGs). Compared to PGs, adult gastroenterologists (AGs) took esophageal biopsies significantly less frequently in the following scenarios: endoscopy without esophageal symptoms or macroscopic endoscopic findings (10% vs 57%; P < 0.001), dysphagia without macroscopic findings (83% vs 100%; P = 0.019), and gastroesophageal reflux symptoms with distal esophageal erythema (44% vs 100%; P < 0.001). Significantly fewer AGs reported taking gastric and duodenal biopsies when EoE was suspected (29% vs 90%; P < 0.001). AGs more often followed patients clinically (30% vs 0%; P < 0.001) rather than endoscopically, and were far less inclined to implement elimination diets compared to PGs (23% vs 68%; P < 0.001). CONCLUSIONS Significant disparities exist between gastroenterologists treating adult and pediatric patients with EoE. These findings may impact rates of diagnosis, appropriate treatment, monitoring, long-term outcomes, and may affect negatively transition from pediatric to adult care.
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Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is rare but incidence and prevalence is increasing. EoE is characterized by eosinophilic inflammation of the esophagus causing gastrointestinal symptoms such as abdominal pain, vomiting, reflux, dysphagia, and food impactions. If untreated, remodeling and fibrosis of the esophagus can occur and stricture formation may result. Current treatment options are limited to food-restriction diets or medications including proton pump inhibitors (PPIs) or swallowed corticosteroids. Significant progress has been made in understanding the underlying mechanisms of EoE allowing for development of drugs that target specific points in EoE pathways. Investigation of these drugs is early with few controlled studies, but many show promise as future treatments. Areas covered: This review will provide an up to date discussion of current therapies and investigational drugs for EoE. Articles used in this review were retrieved from PubMed. Ongoing or completed clinical trials were obtained through clinicaltrials.gov and review of the PharmaProjects database. Expert Opinion: Multiple therapeutic targets have been identified and several have shown efficacy. Work is needed to define appropriate trial outcome measures. Collaboration between government agencies, patient advocacy groups, and investigator-led consortia is critical for completing new clinical trials which should pave the way for new therapies in clinical practice.
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Affiliation(s)
- Robert D Pesek
- a Department of Pediatrics and Division of Allergy and Immunology , University of Arkansas for Medical Sciences and Arkansas Children's Hospital , Little Rock , AR , United States
| | - Sandeep K Gupta
- b Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Illinois , University of Illinois College of Medicine , Peoria , IL , United States
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Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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Munoz-Persy M, Lucendo AJ. Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach. Eur J Pediatr 2018; 177:649-663. [PMID: 29549437 DOI: 10.1007/s00431-018-3129-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022]
Abstract
UNLABELLED Eosinophilic esophagitis (EoE) is a unique form of non-IgE-mediated food allergy characterized by esophageal eosinophilic infiltration that commonly causes dysphagia and food impaction in children and adolescents. Assessing the efficacy of dietary restrictions or drug therapies to achieve clinical and histologic resolution of EoE through randomized controlled trials and meta-analyses has resulted in new evidence-based guidelines. Avoiding food triggers is the only therapy targeting the cause of the disease. None of the currently available food allergy tests adequately predict food triggers for EoE. Exclusively feeding with an amino acid-based elemental diet and empiric six-food elimination diet (avoiding the six foods most commonly related with food allergy) has consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies are deterrents for implementation. Simpler and less restrictive empirical methods, like a four-food (milk, gluten-containing cereals, egg, legumes) or a two-food (milk and gluten) elimination diet, show encouraging results. Proton pump inhibitors are currently a first-line treatment, achieving histological remission and improvement of symptoms in 54.1 and 64.9% of pediatric EoE patients, respectively. The efficacy of topical corticosteroids in EoE assessed in several trials and summarized in meta-analyses indicates that budesonide and fluticasone propionate are significantly superior to placebos, both in decreasing eosinophil mucosal infiltration and in relieving symptoms. Owing to differences in drug delivery, viscous budesonide formulas seem to be the best pharmacological therapy for EoE. CONCLUSION Applying evidence-based therapies and a practical management algorithm provide an effective control of EoE. What is Known: • Eosinophilic esophagitis (EoE) now constitutes the main cause of dysphagia and food impaction in children, adolescents, and young adults. • Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment. What is New: • Therapeutic goals in children with EoE include resolution of esophageal symptoms, to cure esophageal inflammation (mucosal healing) and restore a proper esophageal caliber in case of fibrostenotic endoscopic findings. Avoiding iatrogenic drug effects and nutritional deficiencies, as well as maintaining an adequate quality of life, is also essential. • Novel evidence-based guidelines, endorsed by several European scientific societies, incorporate recent advances in knowledge from several randomized controlled trials and systematic reviews to provide the best standard of care to pediatric patients, by following simple management algorithms.
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Affiliation(s)
- Mery Munoz-Persy
- Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700 Tomelloso, Ciudad Real, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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Roufosse F. Targeting the Interleukin-5 Pathway for Treatment of Eosinophilic Conditions Other than Asthma. Front Med (Lausanne) 2018; 5:49. [PMID: 29682504 PMCID: PMC5897501 DOI: 10.3389/fmed.2018.00049] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/09/2018] [Indexed: 01/01/2023] Open
Abstract
Improved understanding of the contribution of eosinophils to various chronic inflammatory conditions, most notably allergic asthma, has encouraged development of monoclonal antibodies specifically targeting mediators and surface receptors involved in eosinophil expansion and activation. The pivotal role of interleukin-5 (IL-5) in eosinophil biology, its high specificity for this leukocyte subset, and its involvement in the majority of eosinophilic conditions make it a very enticing target for treatment of eosinophil-mediated disorders. Two types of antibodies have been developed to target eosinophils: antibodies against IL-5 (mepolizumab and reslizumab), and an antibody against the IL-5-receptor-alpha-chain (IL-5Rα) (benralizumab). Both types of antibodies prevent IL-5 from engaging its receptor and in addition, anti-IL-5Rα antibodies induce target-cell lysis. They have been shown to reduce circulating eosinophil counts rapidly in humans with various disorders. Herein, a brief overview of the role of IL-5 in eosinophil biology will be presented, followed by a description of the development and characteristics of antibodies targeting IL-5 or its receptor. Results of clinical trials evaluating the efficacy and safety of these new antibodies in diseases (other than eosinophilic asthma) with prominent tissue eosinophilia are reviewed, followed by safety considerations and potential future applications.
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Affiliation(s)
- Florence Roufosse
- Hôpital Erasme, Department of Internal Medicine, Université Libre de Bruxelles, Brussels, Belgium
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Philpott H, Dougherty MK, Reed CC, Caldwell M, Kirk D, Torpy DJ, Dellon ES. Systematic review: adrenal insufficiency secondary to swallowed topical corticosteroids in eosinophilic oesophagitis. Aliment Pharmacol Ther 2018; 47:1071-1078. [PMID: 29508432 PMCID: PMC5867261 DOI: 10.1111/apt.14573] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/05/2018] [Accepted: 01/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Swallowed topical corticosteroids are prescribed for eosinophilic oesophagitis (EoE), but there is a theoretical risk of adrenal insufficiency from their use. AIMS To determine if the use of topical corticosteroids to treat EoE is associated with the development of adrenal insufficiency. METHOD We conducted a systematic review of the published literature from January 1, 1950 to April 1, 2017 using Pubmed, Embase, Web of Science and Cochrane Central. Studies and meeting abstracts were included that described patients with EoE who received swallowed topical corticosteroids and any investigation for adrenal insufficiency. RESULTS The search revealed 1610 unique publications, and 17 met inclusion criteria. There were 7 randomised controlled trials (RCTs), 6 prospective observational studies, 3 retrospective observational studies, and 1 case report. Cortisol measurements were performed on 596 individuals with EoE who received topical corticosteroids. Adrenal testing was abnormal, as defined by each study, in 94/596 patients (crude rate of 15.8%). Only 2 studies were considered to have a low risk of bias, being randomised controlled trials that estimated adrenal insufficiency in the active treatment and placebo groups, before and after treatment. None of the seven randomised controlled trials demonstrated statistically significantly different rates of adrenal insufficiency between topical corticosteroid and placebo over treatment intervals of 2-12 weeks. CONCLUSION Topical corticosteroids were associated with adrenal insufficiency in a minority of patients. Most cases came from uncontrolled observational studies, with widely varying definitions of adrenal insufficiency. Longer follow-up and larger controlled studies are needed to quantify the risk of adrenal insufficiency with maintenance topical corticosteroid therapy in EoE.
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Affiliation(s)
- Hamish Philpott
- Northern Adelaide Local Health Network (NALHN), Department of Gastroenterology Lyell McEwin and Modbury Hospitals, University of Adelaide, South Australia
| | - Michael K. Dougherty
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Marie Caldwell
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Deepa Kirk
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David J. Torpy
- Department of Endocrinology, Royal Adelaide Hospital, University of Adelaide, South Australia
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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