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Dutta P, Shah-Riar P, Bushra SS, Haque SN, Rafa ZI, Hawa F, Chakrabarty S, Dev Nath S, Afrin H, Shama N, Khair F, Maisha S, Kapuria P, Dam B. Recent Trends in the Management of Eosinophilic Esophagitis: A Systematic Review. Cureus 2023; 15:e43221. [PMID: 37692685 PMCID: PMC10490439 DOI: 10.7759/cureus.43221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by inflammation and eosinophilic accumulation of the esophagus, resulting in dysphagia and food impaction. While the exact etiology of EoE remains unclear, it is believed to be triggered by food allergens and dynamic environmental factors, resulting in various clinical manifestations, from inflammation to fibrosis. Although clinical presentation varies with age, the number of eosinophils in esophagogastroduodenal endoscopy remains the diagnostic gold standard. While diet elimination, proton pump inhibitors (PPIs), topical corticosteroids, and biological therapy are promising treatment options for EoE, there are insufficient data to determine the optimal therapeutic treatment approach. Combination therapies - the use of dietary therapies in conjunction with other treatment modalities, such as PPIs, topical corticosteroids, or biologic agents - have also emerged as a potential management strategy for EoE. In this systematic review, we attempt to highlight the recent advances in EoE therapies and provide updated guidance to their management. From 2017 to 2022, we conducted a comprehensive electronic search of PubMed (MEDLINE) using specific keywords related to our objective and eventually included a total of 44 articles.
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Affiliation(s)
- Priyata Dutta
- Internal Medicine, Trinity Health Ann Arbor, Ypsilanti, USA
| | - Prince Shah-Riar
- Internal Medicine, Ibn Sina Medical College, Dhaka, BGD
- Internal Medicine, University Muslim Medical Association Community Clinic, Los Angeles, USA
| | | | | | - Zahin Islam Rafa
- Internal Medicine, Ibn Sina Medical College and Hospital, Dhaka, BGD
| | - Fadi Hawa
- Internal Medicine, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
- Internal Medicine/Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
| | | | - Supti Dev Nath
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | | | - Nishat Shama
- Internal Medicine, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka, BGD
| | - Farzana Khair
- Internal Medicine, Bangladesh Medical College & Hospital, Dhaka, BGD
| | - Sadia Maisha
- Internal Medicine, Sher-e-Bangla Medical College, Barisal, BGD
| | - Progga Kapuria
- Internal Medicine, Z.H. Sikder Women's Medical College and Hospital, Dhaka, BGD
| | - Barna Dam
- Internal Medicine, Kumudini Women's Medical College, Tangail, BGD
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Nistel M, Andrews R, Furuta GT, Atkins D. Elimination Diet or Swallowed Topical Steroid Treatment of Pediatric Eosinophilic Esophagitis: Five-Year Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2516-2523.e2. [PMID: 37263351 PMCID: PMC10525024 DOI: 10.1016/j.jaip.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 05/02/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Mason Nistel
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine; Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Rachel Andrews
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine; Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine; Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Dan Atkins
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine; Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
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Votto M, Raffaele A, De Filippo M, Caimmi S, Brunero M, Riccipetitoni G, Marseglia GL, Licari A. Eosinophilic gastrointestinal disorders in children and adolescents: A single-center experience. Dig Liver Dis 2022; 54:214-220. [PMID: 34274254 DOI: 10.1016/j.dld.2021.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date, few studies have been conducted in Italy on pediatric eosinophilic gastrointestinal diseases (EGIDs). AIMS To assess clinical features of pediatric patients with EGIDs who are followed in a tertiary pediatric center. METHODS From January 2015 to December 2019, we retrospectively enrolled patients with EGIDs, and collected clinical, endoscopic, and histological data. RESULTS We enrolled 112 patients, 75.8% were male. Mean age was 9.3 ± 4.8 years. Diagnosis of EGIDs has increased in the last two years, with non-esophageal EGIDs more prevalent than eosinophilic esophagitis (EoE) (5.1% vs. 4.4%). Approximately 30% of patients had allergic comorbidities, which prevailed in children with EoE. Autism spectrum disorders were common in patients with non-esophageal EGIDs (p = 0.007), a statistically significant finding. In addition, esophageal atresia was associated with EoE (p = 0.04). Most EGIDs patients had normal findings or an inflammatory endoscopic phenotype. Patients with EoE were mainly treated with proton pump inhibitors (PPIs) alone or in combination with swallowed steroids. PPIs, oral steroids, and food-elimination diets were prescribed to patients with non-esophageal EGIDs. CONCLUSION This is the first Italian study revealing an increased frequency of EGIDs in a pediatric population. Further studies are needed to characterize patients with these emerging diseases.
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Affiliation(s)
- Martina Votto
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Alessandro Raffaele
- Pediatric Surgery Unit, Department of Maternal and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Silvia Caimmi
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Brunero
- Pediatric Surgery Unit, Department of Maternal and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanna Riccipetitoni
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Pediatric Surgery Unit, Department of Maternal and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
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Tamarit-Sebastian S, Ferrer-Soler FM, Lucendo AJ. Current options and investigational drugs for the treatment of eosinophilic esophagitis. Expert Opin Investig Drugs 2022; 31:193-210. [DOI: 10.1080/13543784.2022.2033207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sonsoles Tamarit-Sebastian
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
| | - Francisco Miguel Ferrer-Soler
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria Princesa (IIS-IP)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
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Newberry C, Lynch K. Using Diet to Treat Diseases of Esophagus: Back to the Basics. Gastroenterol Clin North Am 2021; 50:959-972. [PMID: 34717881 DOI: 10.1016/j.gtc.2021.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The esophagus plays a crucial role in oral nutrition and digestive pathophysiology. In addition, diet is now considered an important primary or augmentative therapy in several esophageal disease states. This review highlights common dietary therapies used in treating diseases of the esophagus as well as the underlying data that support such practices. Specially, diet and its relationship to swallowing dysfunction, motility disorders, malignancies, and inflammatory mucosal diseases such as gastroesophageal reflux disease and eosinophilic esophagitis is explored.
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Affiliation(s)
- Carolyn Newberry
- Division of Gastroenterology, Weill Cornell Medical Center, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Kristle Lynch
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA 19104, USA.
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Immunogenetic, Molecular and Microbiotic Determinants of Eosinophilic Esophagitis and Clinical Practice-A New Perspective of an Old Disease. Int J Mol Sci 2021; 22:ijms221910830. [PMID: 34639170 PMCID: PMC8509128 DOI: 10.3390/ijms221910830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic oesophagitis (EoE) is a chronic, allergic disease associated with a T-lymphocyte response inducing esophageal eosinophilic infiltration in the esophagus. Inflammation and tissue fibrosis are responsible for the main clinical symptoms such as food impaction and dysphagia. The etiopathogenesis is multifactorial in which genetic and environmental factors coexist. The most common trigger is a non-IgE-mediated food allergy to milk, wheat, egg, soybean, nuts, fish, and seafood. The second factor we focus on is the contribution of genetic variation to the risk of EoE, describing the expression profile of selected genes associated with eosinophilic oesophagitis. We raise the topic of treatment, aiming to eliminate inflammation through an elimination diet and/or use of pharmacologic therapy with the use of proton pump inhibitors or steroids and endoscopic procedures to dilate the esophagus. We demonstrate that early diagnosis and effective treatment prevent the development of food impaction and decreased quality of life. The increasing presence of EoE requires bigger awareness among medical specialists concerning clinical features, the course of EoE, diagnostic tools, and management strategies.
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Lucendo AJ, López-Sánchez P. Targeted Therapies for Eosinophilic Gastrointestinal Disorders. BioDrugs 2021; 34:477-493. [PMID: 32472465 DOI: 10.1007/s40259-020-00427-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The growing recognition of eosinophilic gastrointestinal disorders has revealed the limitations of current treatment (mainly based on dietary modification and corticosteroids), and include refractoriness, high recurrence rates, and the need for long-term therapy. Research efforts, mainly in eosinophilic esophagitis (EoE), have unveiled essential pathophysiological mechanisms leading to these disorders, which bear some similarities to those of atopic manifestations and are shared by eosinophilic gastroenteritis (EGE) and eosinophilic colitis (EC). Novel targeted therapies, some imported from bronchial asthma and atopic dermatitis, are currently being assessed in EoE. The most promising are monoclonal antibodies, including those targeting interleukin (IL)-13 (cendakimab) and IL-4 (dupilumab), with phase 3 trials currently ongoing. The potential of anti-integrin therapy (vedolizumab) and Siglec-8 blockers (antolimab) in EGE are also promising. Non-biological therapies for eosinophilic gut disorders, which include preventing the activation of Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and chemoattractant receptor expressed on T helper 2 cells (CRTH2) signaling pathways, and other potential targets that deserve investigation in eosinophilic gut disorders, are reviewed.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n.,, 13700, Tomelloso, Ciudad Real, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain. .,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
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Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
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.
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9
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Lucendo AJ, Molina-Infante J. Dietary therapy for eosinophilic esophagitis: chances and limitations in the clinical practice. Expert Rev Gastroenterol Hepatol 2020; 14:941-952. [PMID: 32614693 DOI: 10.1080/17474124.2020.1791084] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso , Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa , Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres , Caceres, Spain
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10
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Rossetti D, Isoldi S, Oliva S. Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients. Paediatr Drugs 2020; 22:343-356. [PMID: 32519266 DOI: 10.1007/s40272-020-00398-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Danilo Rossetti
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy.
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Kim EM, Randall C, Betancourt R, Keene S, Lilly A, Fowler M, Dellon ES, Herfarth HH. Mucosal Eosinophilia Is an Independent Predictor of Vedolizumab Efficacy in Inflammatory Bowel Diseases. Inflamm Bowel Dis 2020; 26:1232-1238. [PMID: 31633167 PMCID: PMC7365808 DOI: 10.1093/ibd/izz251] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Peripheral and mucosal eosinophilia may be associated with more aggressive disease in inflammatory bowel disease (IBD) patients. Vedolizumab blocks T lymphocytes, eosinophil adhesion, and extravasation in the gastrointestinal tract. It is not known if mucosal eosinophilia is a predictor for the therapeutic efficacy of vedolizumab. METHODS This was a retrospective cohort study of IBD patients with ileal or colonic biopsies who were off steroids before starting vedolizumab. Biopsies were rereviewed by pathologists, and mean eosinophil density was quantified. Patient characteristics and steroid-free clinical response 6 months after beginning vedolizumab were determined. Features were compared between nonresponders and responders, and multivariable logistic regression was performed to identify predictors of clinical response. RESULTS Of 251 IBD patients starting vedolizumab therapy, 65 patients (48% Crohn's disease, 52% ulcerative colitis) met inclusion criteria. All IBD patients not responding to vedolizumab were more likely to have a higher baseline mean eosinophil count (340 ± 156 vs 236 ± 124; P = 0.004), be previously exposed to an anti-TNF (96% vs 56%; P = 0.001), and be male (58% vs 28%; P = 0.02). Mean eosinophil counts were significantly increased in colonic biopsies in UC nonresponders (438 ± 149 vs 299 ± 145; P = 0.01). A similar trend was seen in CD nonresponders. On multivariable analysis, colonic eosinophil density and prior anti-TNF exposure-and the combination of both-were independent predictors of response. CONCLUSION In ulcerative colitis, colonic eosinophilia and prior anti-TNF exposure were independent predictors of 6-month clinical nonresponse to vedolizumab. Mucosal eosinophil density as a novel biomarker should be explored in larger patient cohorts.Aside from the previous anti-TNF exposure, eosinophil density in the colon of patients with UC is a negative predictor for a steroid-free long-term response to vedolizumab. The degree colonic eosinophilia may be a novel biomarker that should be further explored.
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Affiliation(s)
- Erin M Kim
- Multidisciplinary Center for Inflammatory Bowel Disease, Chapel Hill, NC, USA
| | - Cara Randall
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Renee Betancourt
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Staci Keene
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amy Lilly
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mark Fowler
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Evan S Dellon
- Multidisciplinary Center for Inflammatory Bowel Disease, Chapel Hill, NC, USA,Center for Esophageal Diseases and Swallowing, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Multidisciplinary Center for Inflammatory Bowel Disease, Chapel Hill, NC, USA,Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA,Address correspondence to: Hans H. Herfarth, MD, PhD, Division of Gastroenterology and Hepatology, University of North Carolina, Bioinformatics Building, CB#7080, Chapel Hill, NC, 27599 USA. E-mail:
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12
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Lu CY, Hsieh MS, Wei KC, Ezmerli M, Kuo CH, Chen W. Gastrointestinal involvement of primary skin diseases. J Eur Acad Dermatol Venereol 2020; 34:2766-2774. [PMID: 32455473 DOI: 10.1111/jdv.16676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Abstract
Less is known about gastrointestinal (GI) involvement of primary skin diseases due to the difference in embryology, histology, microbiology and physiology between integument and alimentary tract. Oesophagus, following the oropharyngeal mucosa, is the most common GI segment affected by primary skin diseases, especially by eosinophilic oesophagitis, lichen planus and autoimmune bullous dermatoses like pemphigus vulgaris, mucosal membrane pemphigoid and epidermolysis bullosa acquisita. Eosinophilic oesophagitis is an emerging chronic atopic disease with oesophageal dysfunction as the typical presentation, and oesophageal narrowing, rings and stricture as late complications. Oesophageal lichen planus mainly involves the proximal to mid-oesophagus in elderly aged women with long-term oral mucosal lesions. In acute attack of pemphigus vulgaris, oesophageal involvement is not uncommon but often neglected and may cause sloughing oesophagitis (oesophagitis dissecans superficialis) with acute GI bleeding in rare cases. GI manifestation of hereditary bradykininergic angio-oedema with colicky acute abdomen mostly affects small intestine, usually in the absence of pruritus or urticaria, and is more severe and long-lasting than the acquired histaminergic form. Strong evidence supports association between inflammatory bowel disease, especially Crohn disease, and hidradenitis suppurativa/acne inversa. Patients with vitiligo need surveillance of autoimmune liver disease, autoimmune atrophic gastritis or coeliac disease when corresponding symptoms become suspect. Melanoma is the most common primary tumour metastatic to the GI tract, with small intestine predominantly targeted. Gastrointestinal involvement is not uncommon in disseminated mycosis fungoides. Extramammary Paget's disease is an intraepidermal adenocarcinoma of controversial origin, and a high association between the anogenital occurrence and colorectal adenocarcinoma has been reported. As GI tract is the largest organ system with multidimensional functions, dermatologists in daily practice should be aware of the gastrointestinal morbidities related to primary skin diseases for an early diagnosis and treatment.
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Affiliation(s)
- C-Y Lu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - M-S Hsieh
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - K-C Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - M Ezmerli
- Department of Dermatology, Faculty of Medicine in Rabigh, Kingdom of Saudi Arabia, King Abdulaziz University, Jeddah, Saudi Arabia
| | - C-H Kuo
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - W Chen
- Center for Research & Development, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan.,Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
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Silva FMDCE, de Oliveira EE, Ambrósio MGE, Ayupe MC, de Souza VP, Menegati LM, Reis DRDL, Machado MA, Macedo GC, Ferreira AP. Disodium cromoglycate treatment reduces T H2 immune response and immunohistopathological features in a murine model of Eosinophilic Esophagitis. Int Immunopharmacol 2020; 83:106422. [PMID: 32251959 DOI: 10.1016/j.intimp.2020.106422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/28/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is an emergent chronic disease of the esophagus. The immunopathological process in EoE is characterized by Th2 immune response and prominent eosinophilic influx, in response to common food allergens. The classical treatment consists of allergen elimination diet and systemic/topical corticosteroid therapy. Nevertheless, patients do not always comply to treatment, and the prolonged corticosteroid therapy can cause side effects, therefore, there is an immediate need for new therapeutic approach for EoE. Disodium cromoglicate (DSCG) is a substance broadly used in allergic asthma treatment, and a well-known mast cell activation stabilizer. However, its effect in EoE have not been evaluated yet. This study aimed to assess the effects of DSCG treatment in an EoE experimental model. Male Balb/C mice were subcutaneously sensitized for five days with OVA, and subsequently orally OVA-challenged, DSCG administration was performed between the OVA-challenges. DSCG treatment not only reduced eosinophilic and mast cell influx, as well as reduced fibrosis. In addition, tslp, GATA3, IL-5, FoxP3 and IL-10 mRNA expression were reduced in esophageal mucosa, associated with lower Th2 (CD3+CD4+GATA3+IL4+) and B cells (CD19+CD40+) number in peripheral lymphoid organs. In conclusion, the data demonstrate DSCG treatment was effective in reducing mast cell activation and Th2 immune response, important immunopathological EoE features. Therefore, the use of DSCG as an EoE treatment can be considered a promising therapeutic approach to treat this disease.
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Affiliation(s)
- Flávia Márcia de Castro E Silva
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | - Erick Esteves de Oliveira
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | | | - Marina Caçador Ayupe
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | - Viviane Passos de Souza
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | - Laura Machado Menegati
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | | | | | - Gilson Costa Macedo
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil
| | - Ana Paula Ferreira
- Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, MG, Brazil.
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14
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Casiraghi A, Gennari CG, Musazzi UM, Ortenzi MA, Bordignon S, Minghetti P. Mucoadhesive Budesonide Formulation for the Treatment of Eosinophilic Esophagitis. Pharmaceutics 2020; 12:pharmaceutics12030211. [PMID: 32121553 PMCID: PMC7150804 DOI: 10.3390/pharmaceutics12030211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic esophagitis (EE) is a chronic immune/antigen-mediated esophageal inflammatory disease for which off-label topical corticosteroids (e.g., budesonide) are widely used in clinic. In general, thickening excipients are mixed with industrial products to improve the residence time of the drug on the esophageal mucosa. The compounding procedures are empirical and the composition is not supported by real physicochemical and technological characterization. The current study aimed to propose a standardized budesonide oral formulation intended to improve the resistance time of the drug on the esophageal mucosa for EE treatment. Different placebo and drug-loaded (0.025% w/w) formulations were prepared by changing the percentage of xanthan gum alone or in ratio 1:1 with guar gum. Both excipients were added in the composition for their mucoadhesive properties. The formulative space was rationalized based on the drug physicochemical stability and the main critical quality attributes of the formulation, e.g., rheological properties, syringeability, mucoadhesiveness and in vitro penetration of budesonide in porcine esophageal tissue. The obtained results demonstrated that gums allowed a prolonged residence time. However, the concentration of the mucoadhesive polymer has to be rationalized appropriately to permit the syringeability of the formulation and, therefore, easy dosing by the patient/caregiver.
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Affiliation(s)
- Antonella Casiraghi
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
- Correspondence:
| | - Chiara Grazia Gennari
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
| | - Umberto Maria Musazzi
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
| | - Marco Aldo Ortenzi
- CRC Materiali Polimerici (LaMPo), Department of Chemistry, Università degli Studi di Milano, Via Golgi 19-20133 Milan, Italy;
- Department of Chemistry, Università degli Studi di Milano, Via Golgi 19-20133 Milan, Italy
| | - Susanna Bordignon
- Student of Specialization School in Pharmacy, Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy;
| | - Paola Minghetti
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
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15
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Lucendo AJ. Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies. Expert Rev Clin Immunol 2020; 16:63-77. [PMID: 31842634 DOI: 10.1080/1744666x.2019.1705784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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16
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Hannan N, Steel A, McMillan SS, Tiralongo E. Health Service Use and Treatment Choices for Pediatric Eosinophilic Esophagitis: Findings From a Cross-Sectional Survey of Australian Carers. Front Pediatr 2020; 8:147. [PMID: 32363170 PMCID: PMC7180181 DOI: 10.3389/fped.2020.00147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
Objectives: The incidence and the prevalence of eosinophilic esophagitis (EoE) are increasing, and healthcare utilization among children with EoE is high. This study provides novel insights into the health services and the treatments, including complementary medicines (CMs), used by carers to manage their children's EoE as well as the carers' beliefs and attitudes toward these treatments. Methods: A national cross-sectional online survey was conducted in Australia between September 2018 and February 2019. The survey included questions about health service and treatment utilization, health insurance and government support, health-related quality of life of children with EoE and their carers, views and attitudes toward CM use, and perceived efficacy of treatment. Results: The survey was completed by 181 carers (96.6% of whom were mothers) of EoE children. Most children (91.2%, n = 165) had seen a medical doctor for their EoE, and almost half had consulted with a CM practitioner (40.3%, n = 73). Pharmaceuticals (n = 156, 86.2%) were the most commonly used treatment option, followed by dietary changes (n = 142, 78.5%), CM products (n = 109, 60.2%), and CM therapies (n = 42, 23.2%). Most children received care from numerous practitioners on multiple occasions, indicating a substantial financial and treatment-related burden. Conclusions: A variety of practitioners are involved in the care of children with EoE, and a high rate of CM use warrants further attention to ensure that appropriate treatment is provided. Carer involvement and guidance, combined with individual practitioner expertise, referrals, and collaboration between providers, is essential to successfully navigate this complex disease and provide adequate care for these patients.
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Affiliation(s)
- Nicole Hannan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Amie Steel
- Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
| | - Sara S McMillan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Evelin Tiralongo
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
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17
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Greuter T, Hirano I, Dellon ES. Emerging therapies for eosinophilic esophagitis. J Allergy Clin Immunol 2019; 145:38-45. [PMID: 31705907 DOI: 10.1016/j.jaci.2019.10.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/13/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023]
Abstract
Despite advances in the pathologic understanding of eosinophilic esophagitis (EoE), as of yet, no single agent has been approved by the US Food and Drug Administration to treat EoE. Off-label, EoE is currently treated by using the 3 Ds: drugs (particularly swallowed topical corticosteroids), dietary restriction, and endoscopic dilation. In the recent past, considerable progress in terms of EoE treatment has been made: (1) new EoE-specific steroid formulations optimizing mucosal deposition have been developed, which has culminated in recent approval of a budesonide effervescent tablet in Europe; (2) biologics used for other TH2-mediated diseases, such as allergic asthma and atopic eczema, as well as purpose-developed biologics, have been studied in phase II trials in patients with EoE; and (3) novel dietary restriction strategies have evolved. Finally, further insights into the pathogenesis of EoE have revealed several novel disease mediators that might be targeted in the future. In the following article we will discuss recent advances in EoE treatment with regard to swallowed topical steroids, biological agents, dietary approaches, and novel molecular targets.
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Affiliation(s)
- Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Ill
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, UNC Hospital, Chapel Hill, NC.
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