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Arnim UV, Biedermann L, Aceves SS, Bonis PA, Collins MH, Dellon ES, Furuta GT, Gonsalves N, Gupta S, Hirano I, Lucendo AJ, Miehlke S, Oliva S, Schlag C, Schoepfer A, Straumann A, Vieth M, Bredenoord AJ. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol 2023; 21:2526-2533. [PMID: 36572109 DOI: 10.1016/j.cgh.2022.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS There are no studies or recommendations on optimal monitoring strategies for patients with eosinophilic esophagitis (EoE). Our objective was to develop guidance on how to monitor patients with EoE in routine clinical practice, on the basis of available clinical evidence and expert opinion. METHODS A multidisciplinary, international group of EoE experts identified the following important 3 questions during several consensus meetings: why, by what means, and when to monitor patients with EoE. A steering committee was named, and 3 teams were formed to review literature and to formulate statements for each topic. In a Delphi survey, a level of agreement of ≥75% was defined as threshold value for acceptance. In a final conference, results were presented, critical points and comments on the statements were discussed, and statements were rephrased/rewritten if necessary. RESULTS Eighteen EoE experts (14 adult and pediatric gastroenterologists, 2 pathologists and 2 allergists) with a median of 21.7 years in clinical practice, mostly academic or university-based, completed the Delphi survey, which included 11 statements and a proposed algorithm for monitoring patients with EoE. Each statement attained ≥75% agreement. Participants discussed and debated mostly about the statement concerning surveillance intervals for EoE patients with stable disease. CONCLUSIONS It was concluded that effective maintenance treatment probably reduces the development of EoE complications, and regular, structured, and, under certain conditions, individualized clinical follow-up is recommended to assess disease activity while opening a window to monitoring side effects, adjusting therapy, and encouraging adherence to treatment. Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings.
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Affiliation(s)
- Ulrike von Arnim
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital, Magdeburg, Germany.
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Seema S Aceves
- Eosinophilic Gastrointestinal Disorders Clinic, Division of Allergy Immunology, Rady Children's Hospital, San Diego University of California, San Diego, California
| | | | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Glenn T Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University - Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep Gupta
- Community Hospital Network, Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf, Hamburg, Germany
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Netherlands
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Plevris N, Lees CW. Disease Monitoring in Inflammatory Bowel Disease: Evolving Principles and Possibilities. Gastroenterology 2022; 162:1456-1475.e1. [PMID: 35101422 DOI: 10.1053/j.gastro.2022.01.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease is a progressive and debilitating condition. Early and effective treatment using a treat-to-target approach is key to improving patient outcomes. Therefore, proactive monitoring is essential to ensure that treatment strategies are working and targets are being met. In this review we discuss the current monitoring tools available to us and how they can be used. We also discuss the importance of monitoring during key phases of the disease and propose an optimum treat-to-target monitoring strategy for Crohn's disease and ulcerative colitis. Regarding the advent of new technology, we discuss how this may improve our monitoring capabilities and how we envisage future monitoring strategies of inflammatory bowel diseases.
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Affiliation(s)
- Nikolas Plevris
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, Scotland, United Kingdom; Centre for Genomics and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Campus, Edinburgh, Scotland, United Kingdom
| | - Charlie W Lees
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, Scotland, United Kingdom; Centre for Genomics and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Campus, Edinburgh, Scotland, United Kingdom.
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Dulai PS, Jairath V. How Do We Treat Inflammatory Bowel Diseases to Aim For Endoscopic Remission? Clin Gastroenterol Hepatol 2020; 18:1300-1308. [PMID: 31887449 DOI: 10.1016/j.cgh.2019.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous conditions which may manifest with 1 or more of a constellation of abnormal symptoms, elevated biomarkers, and/or objective evidence of inflammation on endoscopic or cross-sectional evaluation. Whilst resolution of symptoms and restoration of quality of life is the primary goal for patients following a disease flare, there may be discordance between resolution of symptoms, biomarkers, and endoscopy. Increased emphasis is placed on the achievement of endoscopic remission, given it is associated with improved outcomes and reduction in hospitalization and surgeries. As the therapeutic armamentarium for inflammatory bowel disease does not achieve remission in all patients, there is greater emphasis on repetitive interval-based assessment of disease activity with sequential algorithmic treatment adjustments until endoscopic remission is achieved, in a so-called treat-to-target approach. We review the role of symptoms, biomarkers, imaging and endoscopy within treat-to-target algorithms and provide a practical guidance to their use in clinical practice.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, San Diego, California.
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Safroneeva E, Straumann A, Coslovsky M, Zwahlen M, Kuehni CE, Panczak R, Haas NA, Alexander JA, Dellon ES, Gonsalves N, Hirano I, Leung J, Bussmann C, Collins MH, Newbury RO, De Petris G, Smyrk TC, Woosley JT, Yan P, Yang GY, Romero Y, Katzka DA, Furuta GT, Gupta SK, Aceves SS, Chehade M, Spergel JM, Schoepfer AM. Symptoms Have Modest Accuracy in Detecting Endoscopic and Histologic Remission in Adults With Eosinophilic Esophagitis. Gastroenterology 2016; 150:581-590.e4. [PMID: 26584601 PMCID: PMC6011000 DOI: 10.1053/j.gastro.2015.11.004] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/18/2015] [Accepted: 11/05/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS It is not clear whether symptoms alone can be used to estimate the biologic activity of eosinophilic esophagitis (EoE). We aimed to evaluate whether symptoms can be used to identify patients with endoscopic and histologic features of remission. METHODS Between April 2011 and June 2014, we performed a prospective, observational study and recruited 269 consecutive adults with EoE (67% male; median age, 39 years old) in Switzerland and the United States. Patients first completed the validated symptom-based EoE activity index patient-reported outcome instrument and then underwent esophagogastroduodenoscopy with esophageal biopsy collection. Endoscopic and histologic findings were evaluated with a validated grading system and standardized instrument, respectively. Clinical remission was defined as symptom score <20 (range, 0-100); histologic remission was defined as a peak count of <20 eosinophils/mm(2) in a high-power field (corresponds to approximately <5 eosinophils/median high-power field); and endoscopic remission as absence of white exudates, moderate or severe rings, strictures, or combination of furrows and edema. We used receiver operating characteristic analysis to determine the best symptom score cutoff values for detection of remission. RESULTS Of the study subjects, 111 were in clinical remission (41.3%), 79 were in endoscopic remission (29.7%), and 75 were in histologic remission (27.9%). When the symptom score was used as a continuous variable, patients in endoscopic, histologic, and combined (endoscopic and histologic remission) remission were detected with area under the curve values of 0.67, 0.60, and 0.67, respectively. A symptom score of 20 identified patients in endoscopic remission with 65.1% accuracy and histologic remission with 62.1% accuracy; a symptom score of 15 identified patients with both types of remission with 67.7% accuracy. CONCLUSIONS In patients with EoE, endoscopic or histologic remission can be identified with only modest accuracy based on symptoms alone. At any given time, physicians cannot rely on lack of symptoms to make assumptions about lack of biologic disease activity in adults with EoE. ClinicalTrials.gov, Number: NCT00939263.
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Affiliation(s)
- Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alex Straumann
- Swiss EoE Research Group, Praxis Römerhof, Olten, Switzerland,Division of Gastroenterology and Hepatology, University Hospital Basel, Basel, Switzerland
| | - Michael Coslovsky
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia E. Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nadine A. Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nirmala Gonsalves
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ikuo Hirano
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Leung
- Food Allergy Center at Tufts Medical Center and Floating Hospital for Children, Division of Allergy and Immunology, Division of Gastroenterology and Hepatology, Tufts Medical Center, Boston, Massachusetts
| | | | - Margaret H. Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robert O. Newbury
- Department of Pathology, Rady Children’s Hospital, University of California, San Diego, San Diego, California
| | - Giovanni De Petris
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Thomas C. Smyrk
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John T. Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Pu Yan
- Institut Universitaire de Pathologie de Lausanne, Lausanne, Switzerland
| | - Guang-Yu Yang
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Yvonne Romero
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota,GI Outcomes Unit, Mayo Clinic, Rochester, Minnesota
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Glenn T. Furuta
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sandeep K. Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Seema S. Aceves
- Division of Allergy and Immunology, Rady Children’s Hospital, University of California, San Diego, San Diego, California
| | - Mirna Chehade
- Departments of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan M. Spergel
- Divisions of Allergy and Immunology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Philadelphia, Pennsylvania
| | - Alain M. Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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