Food elimination diets are effective for long-term treatment of adults with eosinophilic oesophagitis

Daily or Twice Daily Treatment With Topical Steroids Results in Similar Responses in Eosinophilic Esophagitis

BACKGROUND & AIMS

Few data compare topical corticosteroid (tCS) dosing regimens and outcomes. We aimed to compare treatment outcomes in patients with eosinophilic esophagitis (EoE) by once or twice daily dosing regimens.

METHODS

We conducted a retrospective cohort study using the UNC EoE Clinicopathologic Database of newly diagnosed patients with EoE treated with a tCS who had a follow-up endoscopy with biopsy. Baseline data and outcomes were extracted. Bivariate and multivariate analyses compared patients at baseline and following initial tCS given as a once or twice daily dose.

RESULTS

A total of 522 patients met inclusion criteria, 122 patients on once daily dosing (72% male; 91% white) and 400 patients on twice daily dosing (66% male; 89% white). Patients on twice daily dosing were older (28.8 ± 18.2 vs 24.3 ± 18.0; P = .01) and reported more heartburn (40% vs 25%; P = .004). On bivariate analysis, global symptomatic response (78% vs 76%; P = .82), posttreatment eosinophil count (20.8 ± 27.2 vs 25.6 ± 39.4; P = .21), posttreatment EoE Endoscopic Reference Score (2.2 ± 1.8 vs 2.2 ± 2.0; P = .92), and histologic response (<15 eos/hpf; 56% vs 58%; P = .66) did not differ by dosing frequency. Candida was less frequent with daily dosing (2% vs 8%; P = .04). In multivariate analysis, the odds of histologic response did not differ by dose groups (adjusted odds ratio, 1.03; 95% confidence interval, 0.67-1.60).

CONCLUSIONS

EoE outcomes did not differ by daily or twice daily dosing regimens. These results inform tCS dosing regimens and reassure that both are effective.

Histologic Response or Endoscopic Normalization After Initial Treatment for Eosinophilic Esophagitis in Children Leads to Less Fibrostenosis over Long-Term Follow-Up

BACKGROUND

Untreated eosinophilic esophagitis (EoE) can result in the development of fibrostenosis over time, but there are few data on whether successful treatment in childhood decreases this risk as children with EoE transition to adulthood.

AIM

To determine whether histologic response or endoscopic normalization after EoE treatment is associated with decreased development of fibrostenosis.

METHODS

Pediatric subjects were identified from a large EoE database at an academic referral center. Medical records were reviewed for the primary outcome of fibrostenosis, defined as esophageal stricture, narrowing, or dilation. We assessed the proportion of histologic responders and normal endoscopies at the first, second, and last esophagogastroduodenoscopy (EGD) on record following diagnosis. We created Kaplan-Meier curves to assess time to fibrostenosis and estimated hazard ratios using Cox proportional analysis.

RESULTS

Among 166 patients, the mean age at diagnosis was 10.2 years. Over a mean follow-up time of 4.7 ± 4.5 years, patients had an average of 4.3 ± 4.2 EGDs. The percent of patients with fibrostenosis was 9%, 15%, and 16% at first, second, and last EGD. Patients with histologic response at second follow-up developed fibrostenosis at a lower rate than non-responders (HR = 0.37, 95% CI 0.14-0.99), as did those with normal endoscopic findings at first follow-up (HR = 0.27, 95% CI 0.08-0.90).

CONCLUSIONS

Histologic response and endoscopic normalization lead to lower rates of fibrostenosis in children with EoE. Though the development of fibrostenosis was relatively uncommon, occurring in < 20% of children with EoE who were followed long term, it is reasonable to target treatment goals of histologic response and endoscopic normalization.

Worsening Disease Severity as Measured by I-SEE Associates With Decreased Treatment Response to Topical Steroids in Eosinophilic Esophagitis Patients

BACKGROUND & AIMS

The Index of Severity for Eosinophilic Esophagitis (I-SEE) grades eosinophilic esophagitis (EoE) severity across several domains. We assessed associations between EoE features and severity by I-SEE at diagnosis, and baseline I-SEE and outcomes following topical corticosteroids (tCS).

METHODS

We conducted a retrospective cohort study of newly diagnosed EoE patients. Data were extracted to complete the I-SEE at diagnosis. Disease activity was categorized as mild (I-SEE 1-6), moderate (I-SEE 7-14), or severe (I-SEE ≥15). We compared baseline characteristics by I-SEE category. We assessed if baseline I-SEE associated with treatment response in patients treated with tCS.

RESULTS

Of 1312 patients, there were 657 (50%), 461 (35%), and 194 (15%) with mild, moderate, and severe disease by I-SEE, respectively. Baseline scores were similar for children (8.5 ± 6.6) and adults (8.8 ± 6.5) (P = .37). Compared with mild or moderate disease, patients with severe disease were younger (23.8 ± 19.8 years for severe vs 28.0 ± 19.7 years for mild vs 30.3 ± 17.0 years for moderate; P < .001), had lower body mass index (21.6 ± 7.1 kg/m2 vs 24.4 ± 7.0 kg/m2 vs 25.7 ± 6.8 kg/m2; P < .001), and had longer symptom length preceding diagnosis (9.3 ± 10.5 years vs 5.9 ± 7.5 years vs 7.2 ± 7.9 years; P < .001). The baseline category associated with tCS response, with severe patients less likely to have histologic response (49% vs 55% vs 64%; P = .03 for <15 eosinophils per high-power field) and symptomatic responses, while also having the highest post-treatment eosinophilic esophagitis endoscopic reference scores.

CONCLUSIONS

I-SEE correlated with baseline features in a large EoE cohort, performed similarly in children and adults, and associated with post-treatment responses to tCS. These data support that I-SEE provides prognostic data and suggest that severe disease may benefit from intensive upfront management.

Practice patterns for eosinophilic esophagitis vary widely among Canadian gastroenterologists: a nationwide survey

Introduction

Eosinophilic esophagitis (EoE) is a chronic allergic, type 2, immune-mediated condition of the oesophagus, resulting in dysmotility and oesophageal stricturing. This study aims to identify practice variation among Canadian gastroenterologists treating adults with EoE.

Methods

A cross-sectional, web-based survey was distributed to Canadian gastroenterologists through the Canadian Association of Gastroenterology and administrations of Canadian universities.

Results

Seventy gastroenterologists completed the survey, with 59% working in academic practice or research. Overall, 90% of gastroenterologists require histological evidence of EoE to establish a diagnosis of EoE, while 50% require clinical symptoms of oesophageal dysfunction; 39% of gastroenterologists take less than 5 biopsies when assessing for EoE, with variability in biopsy location. Only 51% of respondents took biopsies in every case presenting with acute food bolus. Proton pump inhibitors were the initial therapy of 70% of gastroenterologists, with 11% using topical steroids. The preferred dietary approach was the 6-food elimination diet in 36%, followed by the 2-food elimination diet in 26%. Overall, 27% of participants did not use histologic improvement and 63% did not use endoscopic improvement to evaluate treatment response. Use of EoE Endoscopic Reference Score (EREFS) is low, with 56% being either unaware of what EREFS is or never using it. Most respondents feel Canadian guidelines would be helpful in their practice.

Conclusions

Eosinophilic esophagitis practice patterns among Canadian gastroenterologists are variable and differ from consensus guidelines. The development of Canadian guidelines and continuing medical education content can be considered to improve the management of EoE in Canada.

Development and Validation of the PICK-UP-STRICS Score to Predict Fibrostenosis in Patients with EoE Prior to Endoscopy

BACKGROUND

Predicting fibrostenotic complications prior to endoscopy in eosinophilic esophagitis (EoE) is challenging and esophageal strictures and narrowing are commonly missed on endoscopy.

AIM

To develop and validate a score to predict fibrostenosis in EoE patients prior to endoscopy.

METHODS

We leveraged a large database of newly diagnosed EoE patients. Fibrostenosis was defined as esophageal stricture, luminal narrowing, or dilation performed during the diagnostic endoscopy. Patients were randomly divided into a development and validation set. We compared features between patients with and without fibrostenosis to inform the initial model and assess predictive ability, as measured by area under curve (AUC). We tested the model in the independent validation set and generated a score to predict low, medium and high fibrostenosis risk.

RESULTS

In 655 newly diagnosed EoE patients in the development set, fibrostenosis was associated with age ≥ 18 years (OR 10.64; 95% CI 5.61-20.17), symptoms for ≥ 5 years prior to diagnosis (OR 2.07; 1.32-3.24), dysphagia (OR 3.72; 1.68-8.22), food impaction (OR 1.68; 1.07-2.62), and lack of abdominal pain (OR 0.28; 0.14-0.60). The model predicted fibrostenosis (AUC = 0.841). In the validation set (n = 654), AUC was preserved (0.831). A scoring system was generated, with scores of ≤ 2 being low risk (< 10% chance of stricture), 2.5-4.5 medium risk (10-50% stricture), and 5-6 high risk (> 50%).

CONCLUSIONS

We developed and validated the PICK-UP-STRICS score to increase suspicion and detection of fibrostenotic disease in EoE using readily available clinical features prior to endoscopy. This score may guide clinical decisions on the need of endoscopic dilation.

Topical Steroids Are Effective and Safe in Patients With Eosinophilic Esophagitis Over a Median of 6.5 Years of Chronic Use

GOALS

To determine long-term efficacy and safety of tCS for treatment of EoE.

BACKGROUND

Maintenance therapy with topical corticosteroids (tCS) is recommended for eosinophilic esophagitis (EoE), but data for long-term use are still needed.

STUDY

This retrospective cohort study assessed newly diagnosed patients with EoE who were treated with a tCS and had a follow-up endoscopy with biopsy after at least 5 years. Histologic symptomatic and endoscopic responses were extracted from medical records. Patients who did and did not have long-term tCS treatment were compared at baseline, and outcomes for patients were assessed at their last endoscopy while on tCS.

RESULTS

Of 431 patients with EoE treated with tCS, 104 met inclusion criteria for long-term use. For patients with long-term tCS use, the median time (IQR) on tCS was 6.5 years (5.4 to 8.8 y). At the last endoscopy, 54% had histologic response (<15 eos/hpf), but those with excellent adherence had a histologic response of 64%. Endoscopic severity also decreased with improved adherence which was strongly associated with EREFS (1.7 vs. 2.8 vs. 4.0 for excellent, good, and poor adherence; P<0.001). Symptomatic response was 68% overall, but only 40% in those with poor adherence (P=0.07). Complications of taking tCS were uncommon (adrenal insufficiency: 1%; osteopenia: 1%; and esophageal candidiasis: 4% at final endoscopy).

CONCLUSIONS

Long-term tCS (median 6.5 y) were generally effective, especially with better adherence, and also safe, with only rare serious complications. These data can be used to help patients make clinical decisions about chronic tCS use in EoE.

Eosinophilic gastrointestinal disorders: a narrative review on clinical perspectives and research gaps in the Asian context

Background and Objective

Eosinophilic gastrointestinal disorders (EGID) are a heterogeneous group of conditions, comprising eosinophilic esophagitis (EoE) and non-EoE EGID which have gained considerable research interest. There are likely to be differences in disease characteristics between populations with distinct dietary, environmental and cultural backgrounds. However much of our understanding on EGID have come from studies from Europe and North America. The aim of this review is to summarize the recent developments and updates in EGID focusing on disease phenotype specifically in Asian patients, and identify opportunities for future research pertaining to disease profile in the Asian population.

Methods

Original studies, systematic reviews, meta-analyses and review articles up to March 2024 were systematically searched on PubMed, with specific focus on newer studies published in the past 10 years. Case reports, conference abstracts and articles that were not published in the English language were excluded.

Key Content and Findings

Prevalence and incidence of EoE and non-EoE EGID have reportedly increased globally over time, but population-based studies are lacking in Asia. Based on heterogeneous data from a limited number of studies from Asia, there are features in epidemiology, clinical phenotype, and treatment response that may be appreciably distinct in Asian patients with EoE and non-EoE EGID, as compared to the Western patient population. Moreover, the efficacy of novel biologic therapies such as dupilumab in the Asian population has not been well-defined.

Conclusions

There is a lack of robust data on many basic aspects of EGID in Asia. There is a pressing need to bridge this gap by building research networks and collaborations across wider regions in Asia, to gather high-quality, multicenter data using standardized and uniform criteria and build a more accurate understanding of EGID in Asian patients.

Optimal Assessment, Treatment, and Monitoring of Adults with Eosinophilic Esophagitis: Strategies to Improve Outcomes

Eosinophilic esophagitis (EoE) is a chronic type 2 inflammation-mediated disease characterized by an eosinophil-predominant inflammation of the esophagus and symptoms of esophageal dysfunction. Relevant treatment outcomes in the setting of EoE include the improvement of histology, symptoms, and endoscopy findings, quality of life (QoL), and the psychological burden of the disease. Established validated tools for the assessment of EoE include questionnaires on dysphagia and QoL (ie, DSQ, EEsAI, and EoE-IQ). More recently, esophageal symptom-specific anxiety and hypervigilance, assessed using the esophageal hypervigilance and anxiety scale (EHAS), have emerged as contributors to disease burden, confirming the importance of psychological aspects in EoE patients. The EoE endoscopic reference score (EREFS) is the only validated endoscopy score in EoE and can quantify mucosal disease burden. However, esophageal panometry using the functional lumen imaging probe (FLIP) and high-resolution manometry (HRM) have shown potential to optimize the assessment of fibrostenotic features of EoE, providing novel insights into the pathophysiology of symptoms. There is a growing number of licenced and off-label therapeutic options in EoE, with various randomized controlled trials demonstrating the efficacy of proton pump inhibitors, topical steroids, food elimination diets, biological drugs, and esophageal dilatation. However, standardized optimal management strategies of EoE are currently lacking. In this review, we provide an overview of established and novel assessment tools in EoE including patient reported outcomes, FLIP panometry, HRM, endoscopy, and histology outcome measures to improve the outcomes of EoE patients. In addition, we summarize available therapeutic options for EoE based on the most recent evidence.

Efficacy of Dietary Therapy for Eosinophilic Esophagitis in Children and Adults: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Several dietary approaches have been used to induce remission in patients with eosinophilic esophagitis (EoE), yielding varied results.

METHODS

We searched the MEDLINE, EMBASE, and Scopus databases up to May 2024 to identify studies including dietary interventions for EoE used as monotherapy. Summary estimates with 95% CIs for achieving <15 eosinophils/HPF were calculated for each approach. Fixed or random effects models were used depending on heterogeneity (I2); publication bias risks were assessed using funnel plot analyses. Subgroup analyses results were compared using meta-regression.

RESULTS

Forty-three studies with 2825 patients were included in quantitative summaries. The overall rate of histologic remission was 60.6% (95% CI, 54.6-66.5%). Effectiveness rates were 94.5% (95% CI, 92.3-96.4%) for elemental diets, 63.9% (95% CI, 58.5-69.2%) for six-food elimination diets, 54.7% (95% CI, 45.7-63.6%) for four-food elimination diets, 44.3% (95% CI, 36.1-52.8%) for two-food elimination diets, 46.4% (95% CI, 40-52.9%) for one-food elimination diets, and 39.5% (95% CI, 30.3-49.2%) for allergy testing-directed food elimination diets. Overall, superior efficacy was noted in children than in adults and in retrospective compared to prospective studies.

CONCLUSION

Diet therapy remains an effective therapeutic asset for pediatric and adult patients with EoE, with increasing efficacy noted as the levels of dietary restriction increase.

The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring

The present document constitutes Part 2 of the EoETALY Consensus Statements guideline on the diagnosis and management of eosinophilic esophagitis (EoE) developed by experts in the field of EoE across Italy (i.e., EoETALY Consensus Group). Part 1 was published as a different document, and included three chapters discussing 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history and 3) diagnosis of EoE. The present work provides guidelines on the management of EoE in two final chapters: 4) treatment and 5) monitoring and follow-up, and also includes considerations on knowledge gaps and a proposed research agenda for the coming years. The guideline was developed through a Delphi process, with grading of the strength and quality of the evidence of the recommendations performed according to accepted GRADE criteria.This document has received the endorsement of three Italian national societies including the Italian Society of Gastroenterology (SIGE), the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). The guidelines also involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.

Eosinophilic esophagitis: Current concepts in diagnosis and management

ABSTRACT

Eosinophilic esophagitis is an antigen-mediated chronic inflammatory disorder that has risen in incidence and prevalence over the past 2 decades. The clinical presentation is variable and consists of mainly esophageal symptoms such as dysphagia, heartburn, food impaction, and vomiting. Current management relies on dietary elimination, proton-pump inhibitors, and topical corticosteroids with different response rates and relapses after treatment discontinuation. With a better understanding of the underlying pathophysiology, many molecules emerged recently as targeted treatment including dupilumab (IL4/IL13 blocker), as the first FDA-approved biological treatment, which has changed the management paradigm.

Dietary composition of adult eosinophilic esophagitis patients is related to disease severity

BACKGROUND

In addition to the elimination diet, dietary composition may influence disease severity in patients with eosinophilic esophagitis (EoE) through modulation of the immune response.

AIM

To explore the immunomodulatory role of nutrition before and during elimination diet in adult EoE patients.

METHODS

Nutritional intake was assessed in 39 Dutch adult EoE patients participating in the Supplemental Elemental Trial (Dutch trial registry NL6014, NTR6778) using 3-day food diaries. In this randomized controlled trial, diagnosed patients received either a four-food elimination diet alone (FFED) or FFED with addition of an amino acid-based formula for 6 weeks. Multiple linear regression analyses were performed to assess associations between the intake of nutrients and food groups per 1000 kCal and peak eosinophil count/high power field (PEC), both at baseline and after 6 weeks.

RESULTS

At baseline, we found a statistically significant negative (thus favorable) relationship between the intake of protein, total fat, phosphorus, zinc, vitamin B12, folate, and milk products and PEC (p < .05), while calcium (p = .058) and full-fat cheese/curd (p = .056) were borderline (favorably) significant. In contrast, total carbohydrates, prepacked fruit juice, and white bread were significantly positively (unfavorable) related to PEC (p < .05), while ultra-processed meals (p = .059) were borderline (unfavorably) significant. After dietary intervention, coffee/tea were significantly negatively (favorably) related to PEC, hummus/legumes were significantly positively (unfavorably) related with PEC, while peanuts were borderline significantly positively related (p = .058).

CONCLUSION

Dietary composition may be related to inflammation in adult EoE patients. High-quality and anti-inflammatory diets may be a promising adjuvant therapy in the dietary management of EoE.

Retrospective cohort study: Effect of age as a barrier to diagnosis of eosinophilic oesophagitis

BACKGROUND

Prior work suggests eosinophilic oesophagitis (EoE) is rare in those aged over 65 years. However, elderly patients with EoE experience a substantial diagnostic delay from symptom onset to diagnosis.

AIMS

To assess if age predicted whether oesophageal biopsies were obtained in patients with EoE symptoms, what clinical features predict EoE in the elderly, and if EoE phenotype differs between elderly and non-elderly patients.

METHODS

We conducted a retrospective cohort study utilising the University of North Carolina (UNC) electronic medical record, EoE clinicopathologic database and UNC endoscopy software from July 2008 to April 2021. A sample of 193 elderly and non-elderly patients with dysphagia, chest pain and/or heartburn were assembled. Patients with EoE were newly diagnosed per contemporaneous guidelines. Patient demographics, clinical characteristics and procedural data were extracted. Summary statistics, bivariate and multivariate analyses were performed.

RESULTS

Of 193 patients, we included 91 elderly (47%) and 102 non-elderly (53%). Age independently predicted the odds of biopsies (adjusted odds ratio (aOR): 0.44 elderly vs. non-elderly; 95% CI: 0.21-0.92). Endoscopic features of EoE, but not symptoms, were more common in elderly than non-EoE elderly patients. Elderly patients with EoE differed from non-elderly only by time to diagnosis (aOR per year of symptoms preceding diagnosis: 1.08, 95% CI: 1.04-1.11).

CONCLUSIONS

Elderly patients with EoE have <50% the odds of oesophageal biopsies. There were no significant differences between elderly and non-elderly EoE patients, although endoscopic features helped discriminate the two groups. Our findings suggest that older age represents a barrier to EoE diagnosis.

Dietary Treatment for Children and Adults with Eosinophilic Esophagitis: Which Patient and Which Doctor Is It Suitable for?

Background

The effectiveness of dietary therapy to induce remission of eosinophilic esophagitis (EoE) has been evaluated over the last decades and summarized in meta-analyses. Choosing the dietary modality, identifying the most suitable patients, and implementing specific prerequisites are essential to ensure long-term success.

Summary

Impractical exclusive elemental diets provided the highest remission rates in EoE; however, they are not recommended due to their numerous disadvantages and detrimental effects on patient quality of life. Allergy testing-guided diets for EoE are limited; their insufficient effectiveness and low reproducibility are due to poor accuracy of skin or serum test results in identifying EoE food triggers. Initial experiences with a six-food elimination diet have provided evidence of high and predictive effectiveness rates and paved the way for less restrictive and more efficient step-up approaches, including four-food, two-food, and most recently, milk elimination diets. Dietary treatment for EoE is challenging for patients and families and requires certain skills to ensure success in the short and long term.

Key Messages

The selection of appropriate patients is essential to ensure the success of and long-term adherence to dietary treatment of EoE. As normal triggers for EoE are commonly found in the staple diet, it is important to ensure adequate nutritional substitutes to avoid nutrient deficiency risks when long-lasting feeding difficulties or extensive restrictions are present. Specialized facilities in dietary therapy should adopt patient-centered and personalized approaches in order to provide timely monitoring and support for complex cases.

[Esofagitis eosinofílica, eficacia de las alternativas terapéuticas en el adulto: revisión sistemática.]

OBJECTIVE

Eosinophilic esophagitis is actually the main cause of dysphagia in adults. The choise of therapy must be agreed with the patient. The objective of this study was to review the scientific literature to determine the efficacy of the different therapeutic options for eosinophilic esophagitis in adults.

METHODS

A search for articles was carried out during the month of February 2023 in the databases PubMed, Web of Science, Scopus and Scielo using the search terms: eosinophilic esophagitis, therapeutics and treatment. Clinical trials and observational studies published in the last ten years in adults were selected.

RESULTS

A total of 1,138 articles were obtained, of which 41 were selected after applying the eligibility criteria. Of the available therapies, the most frequently analyzed treatment was swallowed corticosteroids, followed by elimination diets and proton pump inhibitors. Clinical trials predominated. The studies show results on the efficacy of these therapies in histological and clinical remission, both in induction and in the long-term.

CONCLUSIONS

There are basically three therapies for eosinophilic esophagitis in adults, all of them are superior to placebo in histological and clinical response.

Elimination Diet or Swallowed Topical Steroid Treatment of Pediatric Eosinophilic Esophagitis: Five-Year Outcomes

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus commonly treated with swallowed topical steroids (STS) or elimination diets (EDs). Evidence of a long-term response to EDs in pediatric patients is sparse.

OBJECTIVE

Our study sought to understand the natural history of pediatric EoE treated exclusively with EDs and to examine a similar population of STS-treated EoE subjects. We hypothesized that long-term adherence to an effective ED would result in ongoing EoE disease remission.

METHODS

We conducted a retrospective study of pediatric EoE subjects who had at least 2 visits to a multidisciplinary clinic. Subjects were identified who had (1) a new referral with a suspected diagnosis of EoE; (2) received either EDs or STS alone, and (3) completed both a diagnostic and a posttreatment endoscopy. Concomitant proton-pump inhibitor use was allowed. We collected demographics, clinical features, treatment plans, and associated side effects on each subject. Remission was defined as fewer than 15 eosinophils/high-powered field.

RESULTS

We screened the electronic medical record from 2015 to 2016 for subjects cared for in the Gastrointestinal Eosinophilic Diseases Program who fit criteria for inclusion in this analysis. One hundred ninety-nine subjects were identified, 16 who received exclusive EDs and 15 who were treated with STS. Treatment of these subjects was documented for 4.8 and 5.2 years, respectively (P = .51). Significant differences between the groups were observed in average age at EoE diagnosis (3.5 y ED vs 7.8 y STS; P = .002) and in number of endoscopies (6.6 in ED vs 4.5 in STS; P = .03). Fifteen of 16 subjects treated with ED attained histological remission. The initial effective ED removed a mean of 7.7 foods and the final ED removed a mean of 4 foods. No food impactions or esophageal dilations occurred in the ED group. The STS group required an average of 3.7 dose/formulation changes, 4 subjects required 1 or more dilations, 1 subject had 2 food impactions, and 2 were diagnosed with adrenal insufficiency.

CONCLUSIONS

Treatment with either ED or STS can lead to long-term remission of EoE. In this study, fewer side effects developed in the ED group than the STS group, but the validity of this conclusion is limited by the small sample size and reinforces the need for prospective study to explore these initial findings.

Higher Body Mass Index Is Associated With Decreased Treatment Response to Topical Steroids in Eosinophilic Esophagitis

BACKGROUND & AIMS

Understanding which eosinophilic esophagitis (EoE) patients will respond to treatment with topical corticosteroids (tCS) remains challenging, and it is unknown whether obesity impacts treatment response. This study aimed to determine whether treatment outcomes to tCS in EoE patients vary by body mass index (BMI).

METHODS

This retrospective cohort study of the University of North Carolina EoE Clinicopathologic database assessed subjects age 14 years or older with a new diagnosis of EoE. Their BMI was calculated and histologic, symptom, and endoscopic responses were recorded after tCS treatment. The treatment response of obese (BMI, ≥30 kg/m2) and nonobese EoE status was compared using bivariate and multivariate analyses.

RESULTS

We identified 296 EoE patients treated with tCS. Baseline characteristics were similar, although obese EoE patients had more heartburn and hiatal hernias. Histologic response was higher for those who were nonobese compared with obese at fewer than 15 (61% vs 47%; P = .049) and 6 or fewer (54% vs 38%; P = .02) eosinophils per high-power field, respectively. In addition, nonobese patients had significantly greater endoscopic and symptomatic responses. On multivariate analysis, increasing BMI was associated independently with decreased histologic response after accounting for age, heartburn, dilation, and hiatal hernia whether BMI was assessed as a continuous variable (adjusted odds ratio [aOR], 0.93; 95% CI, 0.89-0.98), as nonobese vs obese (aOR, 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR, 0.46; 95% CI, 0.26-0.84] or obese vs normal [aOR, 0.26; 95% CI, 0.13-0.51]).

CONCLUSIONS

As BMI increases in EoE patients, the odds of histologic, symptomatic, and endoscopic responses to tCS decreases, with obese patients having an approximately 40% decrease in odds of response.

Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis

Dietary therapy for short- and long-term management of eosinophilic esophagitis is an effective yet poorly understood and underutilized treatment strategy. Despite several prospective trials demonstrating the efficacy of dietary therapies, successful clinical implementation is hampered by the need for a multidisciplinary approach including dietitian support and provider expertise. The availability of these resources is not readily available to most gastroenterologists. Without standardized guidance on starting or completing the diet for gastrointestinal providers and/or consulting dietitians, provider attitudes toward dietary therapy vary greatly depending on familiarity and knowledge gaps in using diet therapy. This review aims to summarize evidence in support of dietary therapy in eosinophilic esophagitis while providing guidance on initiation and implementation of dietary therapy for providers.

New approaches to diet therapy for eosinophilic esophagitis

PURPOSE OF REVIEW

An empiric step-up (2-4-6) elimination diet remains the most common dietary approach in clinical practice when treating eosinophilic esophagitis (EoE). However, research in this field has fallen behind pharmacological therapy. This review aims to summarize novel approaches to dietary therapy for EoE.

RECENT FINDINGS

A first prospective multicenter study in 41 pediatric patients (mean age 9 years) has evaluated the efficacy of a cow's milk elimination diet. This dietary approach led to histological remission in 51% of patients, albeit a caveat is that up to 80% of patients were receiving concomitant therapy with proton pump inhibitors. In a series of 18 adult patients with documented milk-induced EoE, ingestión of 400 ml of sterilized milk (boiled for up to 20 min) daily for 8 weeks did not induce histologic relapse in two-thirds of patients.

SUMMARY

Milk elimination diet is effective in one-half of pediatric EoE patients and should likely be the first choice in children with EoE (within a step-up dietary approach). Promising data on tolerance of sterilized milk in adults with milk-induced EoE (66%) merit further replication in children, which may radically improve quality of life for patients and their caregivers.

[Treatment of eosinophilic esophagitis - advancements and perspectives]

In recent years significant progress has been made in the treatment of eosinophilic esophagitis (EoE), especially in the area of topical corticosteroids. Novel EoE-specific formulations have been developed and first approvals have been obtained for induction and maintenance of remission in adult EoE patients with the orodispersible budesonide tablet in Germany and other European and non-EU countries. A novel budesonide oral suspension is currently under priority review by the FDA for first approval in the U.S. In contrast, the scientific evidence on the efficacy of proton pump inhibitors remains limited. Moreover, new biologicals have been identified which showed promising results in phase 2 trials and are now being studied in phase 3. This article aims to summarize and discuss recent advances and perspectives in the treatment of EoE.

Food elimination diets in eosinophilic esophagitis: Practical tips in current management and future directions

Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus characterized by symptoms of esophageal dysfunction and an eosinophil-predominant inflammation. Seminal reports identified the role of food allergens in the pathogenesis of the disease by demonstrating that food avoidance could lead to the resolution of esophageal eosinophilia in EoE patients. Although pharmacological treatments for EoE are increasingly being investigated, the exclusion of trigger foods from the diet still represents a valuable option for patients to achieve and maintain disease remission without drugs. Food elimination diets are variegated, and one size does not fit all. Accordingly, before starting any elimination diet, patients' characteristics should be thoroughly evaluated, and a rigorous management plan should be defined. This review provides practical tips and considerations to succeed in the management of EoE patients undergoing food elimination diets, as well as recent advances and future perspectives on food avoidance strategies.

Worsened Fibrostenotic Outcomes in Eosinophilic Esophagitis Patients Due to COVID-19-Related Endoscopy Cancellations

BACKGROUND

Indirect consequences of COVID-19 in eosinophilic esophagitis (EoE) are not known.

AIM

To determine the impact of COVID-19-related endoscopy cancellations on outcomes in EoE patients.

METHODS

In this retrospective cohort study, we assessed whether adult EoE patients who had routine endoscopy scheduled from mid-March 2020 to May 2020 (pandemic start) were canceled or proceeded, and if canceled, ultimately returned. We extracted clinical, endoscopic, and histologic data for their pre-COVID procedure as well as the next procedure performed, if a patient returned. Outcomes included histologic response (< 15 eos/hpf) and endoscopic severity. Those with delayed care were compared to those who returned as scheduled.

RESULTS

Of 102 patients identified, 75 had procedures canceled, and 20 (27%) never returned. For the 55 who were canceled but returned, mean time between procedures was 1.1 ± 0.7 years with a delay of 0.5 ± 0.3 years. While treatment rates were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%; p = 0.05) and their esophageal diameter had significantly decreased (16.8 mm to 15.0 mm; p < 0.001). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation.

CONCLUSION

Of EoE patients with canceled endoscopies during the beginning of the COVID-19 pandemic, > 25% never returned for care, which is a previously unmeasured impact of the pandemic. Those who returned had > 1 year between procedures with progression of fibrotic features and need for esophageal dilation.

Efficacy of Elimination Diets in Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) can be treated by proton pump inhibitors, topical corticosteroids, or dietary measures. This study systematically assessed the efficacy of 4 major dietary treatment regimens in EoE, updating the evidence presented in a meta-analysis from 2014.

METHODS

Electronic databases such as PubMed, Scopus, and Web of Science, and other sources were searched up to September 2022 to identify studies on dietary treatment of EoE. Based on histologic remission criteria, the efficacy of these treatments was pooled and analyzed with respect to the type of dietary regimen: 6-food elimination diet (SFED), 4-food elimination diet (FFED), 1-food elimination diet (OFED), and a targeted elimination diet (TED). Clinical response rates, food sensitization, and efficacies for a pediatric subpopulation were calculated. Influencing variables on efficacies were estimated via meta-regression analyses.

RESULTS

Thirty-four studies with 1762 patients met the inclusion criteria. The overall rate of histologic remission was 53.8% (95% CI, 48.0%-59.6%), and in the individual dietary groups was 61.3% (95% CI, 53.0%-69.3%) for SFED, 49.4% (95% CI, 32.5%-66.3%) for FFED, 51.4% (95% CI, 42.6%-60.1%) for OFED, and 45.7% (95% CI, 32.0%-59.7%) for TED. Dietary regimen and patient age did not significantly affect rates of histologic remission. The overall rate of clinical response was 80.8% (95% CI, 72.3%-88.2%), with response rates of 92.8% (95% CI, 81.2%-99.6%) for SFED, 74.1% (95% CI, 49.8%-92.6%) for FFED, 87.1% (95% CI, 58.4%-99.9%) for OFED, and 69.0% (95% CI, 50.2%85.3%) for TED.

CONCLUSIONS

Dietary therapy is an effective treatment for EoE patients of any age. The current results could support a trend toward less-restrictive dietary regimens as a primary treatment option.

Long-Term Outcomes of the Six-Food Elimination Diet and Food Reintroduction in a Large Cohort of Adults With Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition with tissue eosinophilia resulting in esophageal dysfunction. The six-food elimination diet (SFED) is an EoE treatment approach that removes milk, wheat, soy, eggs, tree nuts/peanuts, and fish/shellfish. After histologic remission, food reintroduction occurs to identify a food trigger. Outcomes from large series of adults undergoing SFED and food reintroduction as clinical care are not known.

METHODS

A retrospective review (2006-2021) of adult patients with EoE from an academic center was completed. Patients were classified as full responders (<15 eos/hpf) after SFED. If reintroduction was pursued, food triggers identified were recorded.

RESULTS

Two hundred thirteen patients completed SFED. One hundred fifteen patients (54%) had response <15 eos/hpf after SFED. Seventy-seven percent of responders had symptom improvement. Thirty-two percent of initial nonresponders underwent repeat dietary elimination. Fifty-eight percent of patients (n = 123) achieved <15 eos/hpf after either initial or extended SFED. Seventy-eight percent of responders underwent food reintroduction. Sixty-nine percent had 1 food trigger identified, 24% had 2 allergens identified, and 4% had 3 allergens identified. The most common food triggers identified were milk, wheat, and soy.

DISCUSSION

This study describes the largest cohort reported of adult patients with EoE completing SFED with food reintroduction. The overall SFED histologic response was 54%, which increased to 58% with 1 additional round of dietary therapy, suggesting that 31% may respond in a second attempt. Most patients who completed food reintroduction had a single food trigger identified. Dietary elimination with specific food trigger identification is a feasible alternative to medical therapy for adults with EoE.

Gene expression and clinical outcomes after dietary treatment for eosinophilic esophagitis: a prospective study

BACKGROUND

Eosinophilic esophagitis (EoE) is an allergen-mediated disease and elimination diets have proven to be effective to obtain clinical and histological remission. However, the effect of elimination diets on specific EoE transcripts and their clinical correlates is relatively unknown. The main aim of the study was to evaluate the effect of dietary treatment (four-food elimination diet [FFED]) with or without addition of amino acid-based formula (AAF) on a variety of pro-/anti-inflammatory, epithelial/barrier function and remodeling/fibrosis-related markers of disease activity and clinical correlates (eosinophils, symptoms, and endoscopic signs) in adult EoE patients.

METHODS

We conducted an analysis of biopsy samples and data collected during a randomized controlled trial with an elimination diet in adult patients with active EoE (≥15 eosinophils [eos] per high-power field [hpf]). Demographics, symptoms (SDI-score), endoscopic signs (EREFS) and peak eosinophil counts/hpf were recorded at baseline and after 6 weeks of treatment. Transcripts of 10 indicated genes were measured (qPCR) and compared to clinical correlates at baseline and after treatment.

KEY RESULTS

Forty patients (pooled FFED + FFED + AAF) (60% male, age 34.5 (interquartile range [IQR] 29-42.8 years) completed the diet. Peak eosinophil counts/hpf, symptoms and endoscopic signs were significantly decreased after 6 weeks dietary treatment. DSG-1 levels were significantly upregulated from baseline to week 6, whereas IL-13, CAPN-14, IL-5, IL-10, CCL-26, POSTN, TSLP, CPA-3, and TGF-β were significantly downregulated after 6 weeks of diet (all; <0.01). Prior to treatment, upregulation of CAPN-14 and lower levels of DSG-1 were associated with clinical fibrotic phenotypes, whereas upregulation of IL-10 was linked to food impaction phenotypes.

CONCLUSION

These findings strongly suggest that elimination diets, besides a clinical and histological response, are associated with a broad transcriptional response at the level of the esophageal epithelium.

Poor Adherence to Medical and Dietary Treatments in Adult Patients With Eosinophilic Esophagitis

INTRODUCTION

To investigate the adherence to prescribed medical and dietary maintenance treatments in a cohort of adult patients with eosinophilic esophagitis (EoE) and to identify associated factors.

METHODS

In this cross-sectional study, adult patients with EoE who were prescribed medical or dietary maintenance therapy were included. Patients were asked to complete questionnaires concerning treatment adherence (Medication Adherence Rating Scale), beliefs about treatment (Beliefs about Medicine Questionnaire), beliefs about disease (Illness Perception Questionnaire), and current symptoms (Straumann Dysphagia Index).

RESULTS

A total of 177 patients with EoE (71% males) were included, with a median age of 43 years. The overall prevalence of poor adherence to prescribed treatments (Medication Adherence Rating Scale &lt; 21 or Diet Adherence Rating Scale &lt; 21) in this cohort was high, being 41.8%. Medically treated patients seemed less adherent to prescribed treatment compared with patients prescribed a diet (35.1% vs 41.8%, P = 0.320). Multivariate logistic regression analyses identified the following independent factors associated with poor treatment adherence: age &lt;40 years (odds ratio [OR] 2.571, 95% CI 1.195-5.532, P = 0.016), longer disease duration in years (OR 1.130, 95% CI 1.014-1.258, P = 0.027), severe symptoms (Straumann Dysphagia Index) (OR 1.167, 95% CI 1.012-1.345, P = 0.034), and low necessity beliefs (OR 4.423, 95% CI 2.169-9.016, P &lt; 0.001).

DISCUSSION

Adherence to maintenance treatment is poor in many adult patients with EoE. Clinicians should pay more attention to treatment adherence, particularly in younger patients, and discuss the necessity of treatment.

Loss to Follow-Up and Health Care Utilization After Initial Diagnosis of Eosinophilic Esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic disease, but the extent of patient loss to follow-up (LTFU) and health care utilization has not been fully investigated.

AIM

To determine frequency and predictors of LTFU and health care utilization in EoE patients.

METHODS

In this retrospective cohort study, we extracted data from patients with a new diagnosis of EoE. Follow-up time for each patient was calculated as the time from the first diagnostic endoscopy to the last GI-related contact date in the medical record. Patients with and without LTFU were compared, and the volume of EoE-related health care interactions was recorded.

RESULTS

Of 944 EoE cases, 249 (26%) met the definition for LTFU. Major reasons for LTFU were never being scheduled (45%) and inability to contact patients (40%). Factors independently associated with regular follow-up were having insurance (aOR 2.89; 95% CI 1.85-4.50), white race (aOR 2.16; 95% CI 1.37-3.41), and longer symptom length (aOR 1.04 per year; 95% CI 1.01-1.08). At the time of last contact, patients with follow-up had better symptom response (55% vs. 12%; p < 0.001), improved esophageal caliber (14.3 vs. 12.4 mm; p = 0.005), and more histologic response (45% vs. 4% at 15 eos/hpf; p < 0.001). Health care utilization was high, with an average of 4.6 endoscopies and 4.0 clinic visits over the follow-up period.

CONCLUSIONS

LTFU of newly diagnosed EoE cases was common and associated with lack of insurance, non-white race, and shorter symptom duration. Those who followed up had high health care utilization but improved response rates. Strategies are needed to help decrease LTFU in EoE.

A Gap in Care Leads to Progression of Fibrosis in Eosinophilic Esophagitis Patients

BACKGROUND & AIMS

There are few data assessing disease progression in eosinophilic esophagitis (EoE) after diagnosis. We aimed to determine outcomes and assess for progression of fibrosis in patients with EoE with a gap in their regular care.

METHODS

In this retrospective cohort study of newly diagnosed patients with EoE, a "gap" in care was defined as ≥2 years without medical contact for EoE. For inclusion, a gap in care and both pre- and post-gap endoscopies were required. Patients with and without a gap were compared. Data were also compared in gap patients before the gap and after EoE care resumed, and progression of fibrosis and predictors were assessed.

RESULTS

Of 701 patients with EoE, 95 (14%) had a gap in care (mean time without care, 4.8 ± 2.3 years). Post-gap, 12% presented with food impaction requiring emergency evaluation. Compared with pre-gap, patients post-gap had higher endoscopic severity (2.4 vs 1.5; P < .001) and smaller esophageal diameters (11.0 vs 12.7 mm; P = .04). Strictures were more prevalent with longer gap time (P < .05 for trend). Each additional year of gap time increased odds of stricture by 26%, even after accounting for pre-gap dilation. Additionally, of 67 patients without pre-gap fibrosis, 25 (37%) had at least one fibrotic feature (stricture, narrowing, or requiring dilation) post-gap.

CONCLUSIONS

A gap in care of ≥2 years in patients with EoE was associated with signs of increased disease activity, and progression to fibrostenosis was noted, particularly with longer gaps in care. Because EoE can progress to fibrosis even after diagnosis, regular care in patients with EoE is required, perhaps at intervals <2 years.

A Single-Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children

BACKGROUND & AIMS

Cow's milk protein (CMP) is the most common trigger of inflammation in children and adults with eosinophilic esophagitis (EoE). We sought to assess the clinical, endoscopic, and histologic efficacy of dietary elimination of all CMP-containing foods in EoE.

METHODS

We performed a prospective observational study in children with EoE treated with the 1-food elimination diet (1FED), excluding all CMP. Children and their caretakers were educated by a registered dietitian regarding dietary elimination of all CMP-containing foods, with substitutions to meet nutritional needs for optimal growth and development, and daily meal planning. Upper endoscopy with biopsies was performed after 8 to 12 weeks of treatment. The primary end point was histologic remission, defined as fewer than 15 eosinophils per high-power field. Secondary end points were symptomatic, endoscopic, and quality-of-life (QOL) improvements.

RESULTS

Forty-one children (76% male; ages, 9 ± 4 years; 88% white) underwent 1FED education and post-treatment endoscopy with biopsies. Histologic remission occurred in 21 (51%) children, with a decrease in peak eosinophils per high-power field from a median of 50 (interquartile range, 35-70) to a median of 1 (interquartile range, 0-6; P < .0001). Endoscopic abnormalities improved in 24 (59%) patients, while symptoms improved in 25 (61%). Improved symptoms included chest pain, dysphagia, and pocketing/spitting out food. Parents perceived worse QOL, while children perceived improved QOL with the 1FED.

CONCLUSIONS

One-food elimination of CMP-containing foods from the diet induced histologic remission in more than 50% of children with EoE and led to significant improvement in symptoms and endoscopic abnormalities. The ease of implementation and adherence supports the 1FED as first-line dietary treatment.

Current treatment options and long-term outcomes in patients with eosinophilic esophagitis

INTRODUCTION

Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited.

AREAS COVERED

Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term.

EXPERT OPINION

Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.

Effect of amino acid-based formula added to four-food elimination in adult eosinophilic esophagitis patients: A randomized clinical trial

BACKGROUND

Elimination of key foods restricts dietary options in eosinophilic esophagitis (EoE) patients. Addition of amino acid-based formula (AAF) to an elimination diet might facilitate adherence and, therefore, enhance efficacy of dietary management.

AIM

To evaluate whether addition of AAF to a four-food elimination diet (FFED) is more effective than FFED alone in decreasing eosinophilia, endoscopic signs, and clinical outcomes.

METHODS

This randomized controlled trial enrolled 41 adult patients with active EoE (≥15 eosinophils (eos) per high power field (hpf)) at baseline biopsy. Subjects were randomized (1:1 ratio) to groups given a FFED or FFED with addition of AAF providing 30% of their daily energy needs (FFED + AAF). Histological disease activity, endoscopic signs, symptoms, and disease-related quality of life (EoEQoL) were measured at baseline and after 6 weeks of intervention.

RESULTS

Patients (60% male, age 34.5 (interquartile range (IQR) 29-42.8 years)) were randomized to FFED (n = 20) or FFED + AAF (n = 21); 40 participants completed the diet. Complete histological remission (<15 eos/hpf) was achieved in 48% of FFED + AAF subjects (n = 21) vs. 25% of FFED subjects (n = 20), respectively (p = 0.204). Peak eosinophil counts (PEC) decreased significantly in both groups between baseline and week 6, but the change in PEC between groups was not different (p = 0.130). A significant but similar endoscopic and symptomatic reduction was observed in both groups (all; p<0.05). Total EoEQoL scores significantly improved in the FFED + AAF group between baseline and week 6 (p = 0.007), and not in the FFED group.

CONCLUSION

The addition of AAF to a FFED did not lead to a larger decrease in PEC between baseline and 6 weeks, but may result in a significant improvement of QoL in adult EoE patients NL6014 (NTR6778).

Nutritional and Psychological Considerations for Dietary Therapy in Eosinophilic Esophagitis

The step-up empiric elimination diet, starting from one/two food groups of most local allergens remains the current gold standard for a dietary approach in eosinophilic esophagitis (EoE) patients. Milk, followed by wheat and egg, is the most frequent food that triggers EoE in pediatric and adult patients. Elimination diets, with restrictions over four food groups, may be limited to highly motivated patients, in which nutritional counseling is recommended. Malnourishment is uncommon in EoE patients and likely multifactorial (concomitant gastrointestinal eosinophilic disorders or IgE-mediated food allergies, feeding difficulties, abnormal feeding behavior). Avoidant/restrictive food intake disorder in EoE children on highly restrictive diets was lately described and may warrant specific psychological support. As for adults, quality of life may be impaired by symptom severity and dietary restrictions, aside from recently reported food impaction-related specific anxiety in up to 43% of patients. Severe symptoms, feeding dysfunction, and diet restrictions may negatively influence psychosocial adjustment for patients and their caregivers.

Older patients with eosinophilic esophagitis have high treatment response to topical steroids

BACKGROUND

There are few data assessing treatment response in older eosinophilic esophagitis (EoE) patients and we evaluated treatment outcomes to topical corticosteroids (tCS) in this older population.

METHODS

This retrospective cohort study of the UNC EoE Clinicopathologic database included subjects with a new diagnosis of EoE treated with tCS. Histologic responses, global symptom response, and endoscopic changes were recorded. Older EoE patients (≥65 years) were compared to younger EoE patients (<65).

RESULTS

We identified 467 EoE patients treated with tCS, 12 (3%) of whom were ≥65 years. Compared to those <65 years, patients ≥65 had longer symptom duration and worse endoscopy scores, but most clinical features were similar. Post-treatment peak eosinophil counts trended higher in the <65 group (25.0 vs 5.5; p = 0.07). Histological response was greater in the ≥65 population at <15 eos/hpf (92% vs 57%; p = 0.02), ≤6 eos/hpf (83% vs 50%; p = 0.02), and <1 eos/hpf (58% vs 29%; p = 0.03). Older age was independently associated with increased odds of histologic response (adjusted OR 8.48, 95% CI: 1.08-66.4).

CONCLUSIONS

EoE patients ≥65 years had a higher likelihood of responding to tCS therapy, suggesting they should be studied more closely and included in future trials.

Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

BACKGROUND

Little is known about esophageal dilation as a long-term treatment approach for eosinophilic esophagitis (EoE). We examined the impact of a "dilate and wait" strategy on symptom management and safety of patients with EoE.

METHODS

This retrospective cohort study included two patient groups: those who underwent a dilation-predominant approach (≥ 3 dilations as sole therapy or for histologically refractory disease [> 15 eos/hpf]); and those who had routine care (< 3 dilations or histologic response). Group characteristics were compared and outcomes for the dilation-only group assessed.

RESULTS

53/205 patients (26 %) received the dilation-predominant strategy (total 408 dilations), predominantly for histologic treatment nonresponse (75 %). These patients were younger (33 vs. 41 years; P = 0.003), had a narrower baseline esophageal diameter (9.8 vs. 11.5 mm; P = 0.005), underwent more dilations (7.7 vs. 3.4; P < 0.001), but achieved a smaller final diameter (15.7 vs. 16.7 mm; P = 0.01) vs. routine care. With this strategy, 30 patients (57 %) had ongoing symptom improvement, with esophageal caliber change independently associated with symptom response (adjusted odds ratio 1.79, 95 % confidence interval 1.16-2.78); 26 (49 %) used the strategy as a bridge to clinical trials. Over a median follow-up of 1001 days (interquartile range 581-1710), no deaths or dilation-related perforations occurred, but there were nine emergency room visits, including one for post-dilation bleeding and four for food impaction.

CONCLUSIONS

A dilation-predominant long-term treatment strategy allowed for symptom control or bridge to clinical trials for patients with difficult-to-treat EoE. Close follow-up and monitoring for complications are required.

Evidence-based treatments for eosinophilic esophagitis: insights for the clinician

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.

[Treatment of eosinophilic esophagitis - advancements and perspectives]

In recent years significant progress has been made in the treatment of eosinophilic esophagitis (EoE), especially in the area of topical corticosteroids. Novel EoE-specific formulations have been developed and first approvals have been obtained for induction and maintenance of remission in adult EoE patients with the orodispersible budesonide tablet in Germany and other European and non-EU countries. A novel budesonide oral suspension is currently under priority review by the FDA for first approval in the U.S. In contrast, the scientific evidence on the efficacy of proton pump inhibitors remains limited. Moreover, new biologicals have been identified which showed promising results in phase 2 trials and are now being studied in phase 3. This article aims to summarize and discuss recent advances and perspectives in the treatment of EoE.

Dietary Management of Eosinophilic Esophagitis: Tailoring the Approach

Eosinophilic esophagitis (EoE) is a unique form of non-immunoglobulin E-mediated food allergy, restricted to the esophagus, characterized by esophageal eosinophil-predominant inflammation and dysfunction. The diagnosis requires an esophago-gastroduodenoscopy with esophageal biopsies demonstrating active eosinophilic inflammation with 15 or more eosinophils/high-power field, following the exclusion of alternative causes of eosinophilia. Food allergens trigger the disease, withdairy/milk, wheat/gluten, egg, soy/legumes, and seafood the most common. Therapeutic strategies comprise dietary restrictions, proton pump inhibitors, topical corticosteroids, biologic agents, and esophageal dilation when strictures are present. However, avoidance of trigger foods remains the only option targeting the cause, and not the effect, of the disease. Because EoE relapses when treatment is withdrawn, dietary therapy offers a long-term, drug-free alternative to patients who wish to remain off drugs and still be in remission. There are currently multiple dietary management strategies to choose from, each having its specific efficacy, advantages, and disadvantages that both clinicians and patients should acknowledge. In addition, dietary regimens should be tailored around each individual patient to increase the chance of tolerability and long-term adherence. In general, liquid elemental diets devoid of antigens and elimination diets restricting causative foods are valuable options. Designing diets on the basis of food allergy skin tests results is not reliable and should be avoided. This review summarizes the most recent knowledge regarding the clinical use of dietary measures in EoE. We discussed endpoints, rationale, advantages and disadvantages, and tailoring of diets, as well as currently available dietary regimens for EoE.

Dietary Management of Eosinophilic Esophagitis: Man Versus Food or Food Versus Man?

An alternative to pharmacologic management of eosinophilic esophagitis, elimination of food antigens for diet therapy is an effective first-line treatment strategy to induce and maintain symptomatic, histologic, and endoscopic disease remission. The 3 dietary strategies for eosinophilic esophagitis include elemental diet, empiric elimination diet, and targeted elimination diet. We review the studies supporting various diet therapy strategies, practical considerations and challenges for applying an elimination diet, and novel testing to identify triggers and optimize food reintroduction.

Diet Therapy in Eosinophilic Esophagitis. Focus on a Personalized Approach

Eosinophilic esophagitis (EoE) is a chronic allergic disease defined by a marked eosinophilic inflammation and symptoms of esophageal dysfunction. EoE is a heterogeneous disease and severely impacts the quality of life of affected patients. The current therapeutic management of EoE is based on two cornerstones: medication and diet therapy, both effective but limited by several critical issues. The choice of one or the other therapy might depend on the different disease phenotypes (allergic vs. non-allergic, inflammatory vs. fibro-stenotic), patient's age (adult vs. childhood-onset), food habits, patient/family preference, and familiar financial resource. Diet therapy is a successful treatment but limited by low patient adherence, the need for several endoscopies, food restrictions, psychosocial impact, and potential nutritional deficiencies. All these limitations could be effectively overcome with multidisciplinary and personalized management. This review summarizes the most recent evidence on the dietary elimination approaches and will provide a practical guide to clinicians in managing and implementing dietary therapy for patients with EoE.

Treatment with compounded fluticasone suspension improves the clinical, endoscopic, and histologic features of eosinophilic esophagitis

No approved medication exists for the treatment of eosinophilic esophagitis (EoE) in the United States, which forces patients to utilize off-label drugs and/or create their own formulations. We assessed the efficacy of a standardized compounded fluticasone suspension. To do this, we performed a retrospective cohort study identifying all EoE patients treated with compounded fluticasone. Compounded fluticasone was prescribed during routine clinical care and dispensed by a specialty compounding pharmacy. Clinical data were extracted from medical records. Outcomes (symptomatic, endoscopic, and histologic) were assessed after the initial and last compounded fluticasone treatment in our system. There were 27 included patients (mean age 34.2; 67% male; 96% white) treated for a mean length of 5.4 ± 4.4 months. The majority (89%) previously utilized dietary elimination or topical corticosteroids, and many (75%) had primary non-response or secondary loss of response to these treatments. After starting compounded fluticasone, symptoms and endoscopic findings improved [dysphagia (89 vs. 56%, P = 0.005), food impaction (59 vs. 4%, P = 0.003), heartburn (26 vs. 4%, P = 0.01), chest pain (26 vs. 8%, P = 0.05), white plaques (63 vs. 32%; P = 0.005), furrows (81 vs. 60%; P = 0.06), and edema (15 vs. 4%; P = 0.16)]. The median of the peak eosinophil counts decreased from 52 to 37 eos/hpf (P = 0.10) and 35% of patients achieved <15 eos/hpf. In conclusion, compounded fluticasone provided a significant improvement in symptoms and endoscopic findings, with more than a third achieving histologic response in a treatment refractory EoE population. Compounded fluticasone should be considered as an EoE management option.

Nutritional approach to eosinophilic esophagitis: which diet and when

Dietary elimination therapy has been for a long time an option for patients with eosinophilic esophagitis (EoE) and remains the only therapy targeting the cause of the disease. Different dietary approaches have been described along the last 3 decades, and cumulative evidence has defined the effectiveness and usefulness of each approach. Elemental diets are highly effective to induce EoE remission, but unpractical in most patients. Allergy testing-directed food restrictions resulted inefficient to induce remission in a significant proportion of patients (especially adults) and show a low concordance with the dietary causes of EoE. Empiric elimination diets are currently considered the most effective drug-free treatment for patients of all ages with EoE, after widely providing reproducible results. Highly restrictive empiric six-food elimination diets have paved the way to most efficient and less restrictive step-up approaches, which now include four-food and two-food elimination diets. The potential role of milk-elimination, especially in children, should be also considered. Multiple factors including demographics, nutritional status, patient and family lifestyles, social and financial support, and acceptance of repeated endoscopies influence the results of dietary therapy. Dietary therapy in EoE should be patient centered, and the patients and/or their families together with the medical provider should participate in the decision to set up this treatment. This article updates recent knowledge on dietary therapy for EoE and provides guideline to choose the most suitable alternative for patients with EoE, as well as practical tips to achieve the best results in clinical practice.

Relationship Between Housing Components and Development of Eosinophilic Esophagitis

BACKGROUND

While the environment contributes to EoE pathogenesis, few environmental risk factors for EoE have been identified.

AIM

To determine whether housing components such as exterior materials, heating systems, and house age are associated with EoE.

METHODS

This case-control study used the UNC EoE clinicopathologic database to identify newly diagnosed EoE patients. Controls were patients without EoE who underwent endoscopy during the study time frame. Housing data were collected from publicly available online sources, and cases and controls were compared. The primary analysis was restricted to those living at their provided address at the time of diagnostic endoscopy. Multivariable logistical regression estimated associations after adjusting for potential confounders.

RESULTS

Of 451 EoE cases and 2421 controls identified, the primary analysis included 158 cases and 769 controls. Compared to controls, EoE cases were more likely to have a house with a brick exterior (35% vs 26%; p = 0.04), gas heating (14% vs 8%; p = 0.06), or forced air (57% vs 45%; p = 0.009). In adjusted analysis, brick exterior was positively associated with EoE diagnosis [aOR 1.83 (95% CI 1.11-3.02)]. The average duration a patient lived in their house before EoE diagnosis was 7.2 ± 5.9 years, while symptom duration prior to diagnosis was 6.8 ± 8.4 years.

CONCLUSION

EoE patients were more likely to have houses with a brick exterior, forced air, or gas heating, and brick exteriors were independently associated with EoE. Since symptoms generally started after moving into a house, housing-related environmental exposures may contribute to EoE disease development.

Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.

Dietary therapy for eosinophilic esophagitis: chances and limitations in the clinical practice

INTRODUCTION

Eosinophilic esophagitis (EoE) is a non-Immunoglobulin E-mediated food allergy that currently represents the main cause of dysphagia and food impaction in children and young adults. Diet remains the only therapy targeting the cause of the disease. Relevant advances in recent years allow novel approaches to dietary therapy in EoE.

AREAS COVERED

An up-to-date review on dietary therapy for EoE is provided, as a potential first-line anti-inflammatory therapy able to induce and maintain remission in a significant proportion of patients. Unpractical elemental diets and suboptimal food allergy testing-directed food restrictions paved the way for empiric elimination diets, which currently are to be considered as the most effective drug-free treatment for EoE. After largely restrictive empiric six-food elimination diets, most efficient step-up approaches now include four-food and two-food elimination diets. The potential of milk-elimination is also discussed.

EXPERT COMMENTARY

An empiric elimination diet step-up strategy should be currently considered as the initial approach for dietary treatment in EoE patients of all ages. Compared to a top-down strategy, step-up diets reduce the need for endoscopic procedures, shorten diagnostic process times, and avoid unnecessary restrictions. Furthermore, early identification of responders with few food triggers may select best candidates for maintenance dietary therapy.

A Novel Allergen-Specific Immune Signature-Directed Approach to Dietary Elimination in Eosinophilic Esophagitis

OBJECTIVES:

Dietary elimination for treatment of eosinophilic esophagitis (EoE) is limited by lack of accuracy in current allergy tests. We aimed to develop an immunologic approach to identify dietary triggers and prospectively test allergen-specific immune signature-guided dietary elimination therapy.

METHODS:

In the first phase, we developed and assessed 2 methods for determining selected food triggers using samples from 24 adults with EoE: a CD4+ T-cell proliferation assay in peripheral blood and food-specific tissue IgG4 levels in esophageal biopsies. In the second phase, we clinically tested elimination diets created from these methods in a prospective cohort treated for 6 weeks (NCT02722148). Outcomes included peak eosinophil counts (eos/hpf), endoscopic findings (measured by the EoE Endoscopic Reference Score), and symptoms (measured by the EoE Symptom Activity Index).

RESULTS:

Parameters were optimized with a positive test on either assay, yielding agreements of 60%, 75%, 53%, 58%, and 53% between predicted and known triggers of peanut, egg, soy, wheat, and milk, respectively. In clinical testing, the mean number of foods eliminated based on the assays was 3.4, and 19 of 22 subjects were compliant with treatment. After treatment, median peak eosinophil counts decreased from 75 to 35 (P = 0.007); there were 4 histologic responders (21%). The EoE Endoscopic Reference Score and EoE Symptom Activity Index score also decreased after treatment (4.6 vs 3.0; P = 0.002; and 32.5 vs 25.0; P = 0.06, respectively).

DISCUSSION:

We successfully developed a new testing approach using CD4⁺ T-cell proliferation and esophageal food-specific IgG4 levels, with promising accuracy rates. In clinical testing, this led to improvement in eosinophil counts, endoscopic severity, and symptoms of dysphagia, but a smaller than expected number of patients achieved histologic remission.

Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder characterized by symptomatic esophageal dysfunction and an eosinophil-predominant inflammation of the esophagus. EoE arises from interaction between genetic and environmental factors. In pediatric patients, clinical manifestations vary depending on age, from a gastroesophageal reflux disease (GERD)-like condition to severe dysphagic symptoms. Upper endoscopy is considered the gold standard for diagnosis and monitoring of EoE; however, significant efforts are underway to identify noninvasive diagnostic tools and biomarkers to avoid repetitive invasive procedures. Therapeutic first-line options currently available for EoE are elimination diets, proton pump inhibitors (PPIs), and steroids. The aim of treatment is to improve clinical symptoms while obtaining mucosal healing and avoiding long-term complications. Dietary treatment options comprise different empiric diets or an exclusively amino acid formula. Despite the efficacy of diets, compliance is often challenging. PPIs and topical steroids represent the main pharmacological options for EoE, and both can induce and maintain remission. Topical steroids have been reported as more effective, but data on long-term safety remain insufficient for both these and PPIs. Endoscopic dilations are currently reserved for severe untreated fibrostenotic disease unresponsive to medical therapies. Several biologic agents are available but not yet approved for EoE.