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Schlager H, Baumann-Durchschein F, Steidl K, Häfner M, Dinkhauser P, Weitersberger M, Holzinger J, Mader M, Gröchenig HP, Madl C, Schreiner P. Diagnosis and management of eosinophilic esophagitis and esophageal food impaction in adults : A position paper issued by the Austrian Society of Gastroenterology and Hepatology (ÖGGH). Wien Klin Wochenschr 2024; 136:479-499. [PMID: 39230674 DOI: 10.1007/s00508-024-02401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/21/2024] [Indexed: 09/05/2024]
Abstract
This position paper deals with an expert consensus on diagnosis and management of eosinophilic esophagitis and esophageal food impaction issued by the Austrian Eosinophilic Esophagitis Network, a working group under the patronage of the Austrian Society of Gastroenterology and Hepatology (ÖGGH). In need of a standardized approach on the management of EoE, recommendations were made based on international guidelines and landmark studies.
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Affiliation(s)
- Hansjörg Schlager
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
| | - Franziska Baumann-Durchschein
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Karin Steidl
- Department of Internal Medicine, Barmherzige Brüder St. Veit/Glan, St. Veit, Austria
| | - Michael Häfner
- 2nd Medical Department, Barmherzige Schwestern Krankenhaus, Vienna, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Division of Gastroenterology and Hepatology, Endocrinology and Rheumatology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michael Weitersberger
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Josef Holzinger
- Department of Surgery, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Salzburg, Austria
| | - Markus Mader
- Department of Internal Medicine II, Universitätsklinikum St. Pölten-Karl Landsteiner Privatuniversität, St. Pölten, Austria
| | - Hans Peter Gröchenig
- Department of Internal Medicine, Barmherzige Brüder St. Veit/Glan, St. Veit, Austria
| | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Philipp Schreiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth MKH, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024; 79:394-437. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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Martin LJ, Zhang X, Chehade M, Davis CM, Dellon ES, Falk GW, Gupta SK, Hirano I, Hiremath GS, Katzka DA, Khoury P, Leung J, Menard-Katcher P, Gonsalves N, Pesek RD, Spergel JM, Wechsler JB, Kliewer K, Arva NC, Collins MH, Pletneva M, Yang GY, Furuta GT, Rothenberg ME, Aceves SS. Long-term durability between parent and child patient-reported outcomes in eosinophilic esophagitis. J Allergy Clin Immunol 2024:S0091-6749(24)00740-1. [PMID: 39059504 DOI: 10.1016/j.jaci.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/11/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Because young children cannot self-report symptoms, there is a need for parent surrogate reports. Although early work suggested parent-child alignment for eosinophil esophagitis (EoE) patient-reported outcomes (PROs), the longitudinal alignment is unclear. OBJECTIVE We sought to assess the agreement and longitudinal stability of PROs between children with EoE and their parents. METHODS A total of 292 parent-child respondents completed 723 questionnaires over 5 years in an observational trial in the Consortium of Eosinophilic Gastrointestinal Disease Researchers. The change in and agreement between parent and child Pediatric Eosinophilic Esophagitis Symptom Score version 2 (PEESSv2.0) and Pediatric Quality of Life Eosinophilic Esophagitis Module (PedsQL-EoE) PROs over time were assessed using Pearson correlation and Bland-Altman analyses. Clinical factors influencing PROs and their agreement were evaluated using linear mixed models. RESULTS The cohort had a median disease duration equaling 3.7 years and was predominantly male (73.6%) and White (85.3%). Child and parent PEESSv2.0 response groups were identified and were stable over time. There was strong correlation between child and parent reports (PEESSv2.0, 0.83;PedsQL-EoE, 0.74), with minimal pairwise differences for symptoms. Longitudinally, parent-reported PedsQL-EoE scores were stable (P ≥ .32), whereas child-reported PedsQL-EoE scores improved (P = .026). A larger difference in parent and child PedsQL-EoE reports was associated with younger age (P < .001), and differences were driven by psychosocial PRO domains. CONCLUSIONS There is strong longitudinal alignment between child and parent reports using EoE PROs. These data provide evidence that parent report is a stable proxy for objective EoE symptoms in their children.
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Affiliation(s)
- Lisa J Martin
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Xue Zhang
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carla M Davis
- Division of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex; Food Allergy Program, Texas Children's Hospital, Houston, Tex
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC; Division of Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Sandeep K Gupta
- Children's of Alabama, University of Alabama at Birmingham, Birmingham, Ala
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Kenneth Griffin Esophageal Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Girish S Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY
| | - Paneez Khoury
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - John Leung
- Division of Allergy/Immunology, Tuft's Medical Center, Boston, Mass; Division of Gastroenterology, Tuft's Medical Center, Boston, Mass
| | - Paul Menard-Katcher
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Kenneth Griffin Esophageal Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Jonathan M Spergel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Kara Kliewer
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicoleta C Arva
- Department of Pathology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Margaret H Collins
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maria Pletneva
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital of Colorado, Aurora, Colo; Gastrointestinal Eosinophilic Disease Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Seema S Aceves
- University of California San Diego, Rady Children's Hospital of San Diego, San Diego, Calif.
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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis 2024; 56:1173-1184. [PMID: 38521670 DOI: 10.1016/j.dld.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/11/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
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.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, 00189, Rome, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, 27100, Pavia, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit, 'Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84084, Baronissi, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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Falk GW, Pesek R. Pharmacologic Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:245-264. [PMID: 38575221 DOI: 10.1016/j.iac.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Proton pump inhibitors (PPIs), swallowed topical corticosteroids (STSs), and dupilumab are highly effective therapies for the treatment of eosinophilic esophagitis. Shared decision-making informs the choice of therapy and factors such as ease of use, safety, cost, and efficacy should be addressed. PPIs are the most common medication utilized early in the disease course; however, for nonresponders, STSs are an excellent alternative. Dupilumab is unlikely to replace PPIs or STSs as first-line therapy, except in highly specific circumstances. Identification of novel biologic pathways and the development of small molecules may lead to a wider range of treatment options in the future.
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Affiliation(s)
- Gary W Falk
- Division of Gastroenterology & Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 7th Floor South Pavilion PCAM, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robbie Pesek
- Division of Allergy and Immunology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA.
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Ramanan SP, Singh B, Gandhamaneni SH, Sange I. Eosinophilic Esophagitis: The Role of Steroids and the Dose, Duration, and Delivery of Steroid Therapy. Cureus 2024; 16:e58343. [PMID: 38756322 PMCID: PMC11097238 DOI: 10.7759/cureus.58343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by the eosinophil infiltration of the esophagus (>15 per high power field). Recently, there has been an increase in both the incidence and prevalence of the disease. The common modalities of treatment are dietary modification, proton pump inhibitors, and steroids. However, the United States Food and Drug Administration has not approved any drugs for the treatment of EoE. This review has discussed the role of steroids in the treatment of EoE, focusing on the various formulations of the drug, its dosage, drug delivery, and duration of therapy. The study also covers the common outcomes of steroid therapy and its side effects.
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Affiliation(s)
- Sruthi Priyavadhana Ramanan
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine/Surgery, Saveetha Medical College, Chennai, IND
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | - Bipneet Singh
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | | | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Karamshibhai Jethabhai Somaiya Medical College, Hospital & Research Center, Mumbai, IND
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7
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Massironi S, Elvevi A, Panceri R, Mulinacci G, Colella G, Biondi A, Invernizzi P, Danese S, Vespa E. Eosinophilic esophagitis: does age matter? Expert Rev Clin Immunol 2024; 20:211-223. [PMID: 37870118 DOI: 10.1080/1744666x.2023.2274940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus with increasing prevalence worldwide. It is a multifactorial disease caused by a combination of immunologic, genetic, and environmental factors. The clinical presentation of EoE varies largely, especially between different age groups. While diagnostic criteria and therapeutic goals are similar in children and adults, there are differences in treatment, with a more cautious approach in children to avoid growth disturbances. In addition, close monitoring and follow-up are essential in children to ensure uninterrupted growth. AREAS COVERED A search in PubMed/MEDLINE, EMBASE, and SCOPUS databases was conducted to identify relevant studies published between January 2010 and January 2023 to give an overview of the state-of-the-art of EoE epidemiology, diagnosis, and treatment while focusing on similarities and differences between the adult and the pediatric population. EXPERT OPINION The current state of research indicates that while significant progress has been made in understanding and treating EoE, further research and advances are needed to optimize diagnostic strategies, tailored treatment approaches, monitoring, and follow-up, and improve long-term outcomes for patients. With further innovation, the management of EoE can become more precise and tailored, leading to better patient outcomes and improved quality of life.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Roberto Panceri
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Giacomo Mulinacci
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giacomo Colella
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Andrea Biondi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Pietro Invernizzi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
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Ferrelli RS, Machado RS, Ogata SK. Oesophageal wall thickness assessment at endoscopic ultrasound in children and adolescents with eosinophilic oesophagitis: a case-control study. J Ultrasound 2023; 26:785-791. [PMID: 36574193 PMCID: PMC10632350 DOI: 10.1007/s40477-022-00742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/06/2022] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease, and an endosonographic evaluation may help the diagnosis. The main objectives of this study were to measure the thickness of the oesophageal wall using a radial endoscopic ultrasound (EUS), mucosa/submucosa (MSM), muscularis propria (MP) and mucosa to muscularis propria (MMP); to compare these measurements between patients with and without EoE; to correlate them with the Endoscopic Reference Score (EREFS); and to evaluate the diagnostic accuracy of these measurements. METHODS Children and adolescents (aging from 4 to 17 years) were evaluated in this prospective cross-sectional study. A radial EUS at 12 MHz frequency was used, and EREFS was employed to grade macroscopic findings. Accuracy of the measurements for the diagnosis of EoE was assessed by receiver operating characteristics (ROC) curve. RESULTS Twenty-six (19 M/7 F) patients (median age 10.83 years, range 5.65-17.46) were evaluated. EoE was diagnosed in 6 patients. The mean (and SD) oesophageal wall thicknesses in the distal oesophagus in millimetres in groups with and without EoE, respectively, were: MSM 1.07 (0.44) and 1.11 (0.33); MP 0.67 (0.25) and 0.60 (0.19); and MMP 1.73 (0.46) and 1.72 (0.32). Mid-oesophagus: MSM 1.16 (0.34) and 1.15 (0.34); MP 0.63 (0.16) and 0.60 (0.2); and MMP 1.79 (0.41) and 1.74 (0.34). In the ROC curve, the distal MP layer thickness presented better discriminative performance, with an area under the curve of 0.61 (95% CI 0.28-0.93) at 0.73 mm cut-off (66.67% sensitivity, 80% specificity, likelihood ratios of 3.33 for positive and 0.42 for negative test). CONCLUSION The evaluation of oesophageal thickness measurements by EUS is not useful for diagnosing EoE.
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Affiliation(s)
- Regis Schander Ferrelli
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil.
| | - Rodrigo Strehl Machado
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil
| | - Silvio Kazuo Ogata
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil
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Sharlin CS, Mukkada VA, Putnam PE, Bolton SM. Treatment of Pediatric Eosinophilic Esophagitis: Traditional and Novel Therapies. Curr Gastroenterol Rep 2023; 25:289-298. [PMID: 37658151 DOI: 10.1007/s11894-023-00893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE OF REVIEW This review presents and summarizes the existing studies on the treatment goals and options for pediatric eosinophilic esophagitis utilizing rigorous peer-reviewed literature. RECENT FINDINGS In addition to traditional treatments, emerging biologic therapies continue to evolve the approach to treating pediatric eosinophilic esophagitis. Well defined treatment goals will aid the continued development of new therapies. Further, innovative assessment tools have changed how the clinician is able to assess the effectiveness of therapies with a trend toward less invasive options. The management of pediatric eosinophilic esophagitis continues to evolve with the advent of both novel treatment options and assessment tools. Treatment choices, with benefits and risks involved, should be presented to families upon diagnosis and tailored towards the individual patient and likelihood of adherence and success. Biologic therapy for EoE presents an exciting option for both first line therapy and escalation for those with severe or unresponsive disease.
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Affiliation(s)
- Colby S Sharlin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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Uchida AM, Burk CM, Rothenberg ME, Furuta GT, Spergel JM. Recent Advances in the Treatment of Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2654-2663. [PMID: 37391018 PMCID: PMC10530275 DOI: 10.1016/j.jaip.2023.06.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/26/2023] [Accepted: 06/13/2023] [Indexed: 07/02/2023]
Abstract
Eosinophilic esophagitis is an increasingly common inflammatory allergic disease of the esophagus characterized by esophageal eosinophilia and symptoms of esophageal dysfunction. The therapeutic landscape has rapidly evolved for this emerging type 2 inflammatory disorder. We review traditional therapies including updates and expert opinions in addition to promising therapies on the horizon and the history of therapies that failed to meet end points and highlight knowledge gaps for future investigations.
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Affiliation(s)
- Amiko M Uchida
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah
| | - Caitlin M Burk
- Food Allergy Center and Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Mass.
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
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Franciosi JP, Gordon M, Sinopoulou V, Dellon ES, Gupta SK, Reed CC, Gutiérrez-Junquera C, Venkatesh RD, Erwin EA, Egiz A, Elleithy A, Mougey EB. Medical treatment of eosinophilic esophagitis. Cochrane Database Syst Rev 2023; 7:CD004065. [PMID: 37470293 PMCID: PMC10358040 DOI: 10.1002/14651858.cd004065.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic antigen-mediated eosinophilic inflammatory disease isolated to the esophagus. As a clinicopathologic disorder, a diagnosis of EoE requires a constellation of clinical symptoms of esophageal dysfunction and histologic findings (at least 15 eosinophils/high-powered microscope field (eos/hpf)). Current guidelines no longer require the failure of response to proton pump inhibitor medications to establish a diagnosis of EoE, but continue to suggest the exclusion of other etiologies of esophageal eosinophilia. The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications. Currently, there is no cure for EoE, making long-term treatment necessary. Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy. Effective pharmacologic therapies include corticosteroids, rapidly emerging biological therapies, and proton pump inhibitor medications. OBJECTIVES To evaluate the efficacy and safety of medical interventions for people with eosinophilic esophagitis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP to 3 March 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of eosinophilic esophagitis, either alone or in combination, to any other intervention (including placebo). DATA COLLECTION AND ANALYSIS Pairs of review authors independently selected studies and conducted data extraction and risk of bias assessment. We expressed outcomes as a risk ratio (RR) and as the mean or standardized mean difference (MD/SMD) with 95% confidence interval (CI). We assessed the certainty of the evidence using GRADE. Our primary outcomes were: clinical, histological, and endoscopic improvement, and withdrawals due to adverse events. Secondary outcomes were: serious and total adverse events, and quality of life. MAIN RESULTS We included 41 RCTs with 3253 participants. Eleven studies included pediatric patients while the rest recruited both children and adults. Four studies were in patients with inactive disease while the rest were in patients with active disease. We identified 19 intervention comparisons. In this abstract we present the results of the primary outcomes for the two main comparisons: corticosteroids versus placebo and biologics versus placebo, based on the prespecified outcomes defined of the primary studies. Fourteen studies compared corticosteroids to placebo for induction of remission and the risk of bias for these studies was mostly low. Corticosteroids may lead to slightly better clinical improvement (20% higher), measured dichotomously (risk ratio (RR) 1.74, 95% CI 1.08 to 2.80; 6 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNTB) = 4; low certainty), and may lead to slightly better clinical improvement, measured continuously (standard mean difference (SMD) 0.51, 95% CI 0.17 to 0.85; 5 studies, 475 participants; low certainty). Corticosteroids lead to a large histological improvement (63% higher), measured dichotomously (RR 11.94, 95% CI 6.56 to 21.75; 12 studies, 978 participants; NNTB = 3; high certainty), and may lead to histological improvement, measured continuously (SMD 1.42, 95% CI 1.02 to 1.82; 5 studies, 449 participants; low certainty). Corticosteroids may lead to little to no endoscopic improvement, measured dichotomously (RR 2.60, 95% CI 0.82 to 8.19; 5 studies, 596 participants; low certainty), and may lead to endoscopic improvement, measured continuously (SMD 1.33, 95% CI 0.59 to 2.08; 5 studies, 596 participants; low certainty). Corticosteroids may lead to slightly fewer withdrawals due to adverse events (RR 0.64, 95% CI 0.43 to 0.96; 14 studies, 1032 participants; low certainty). Nine studies compared biologics to placebo for induction of remission. Biologics may result in little to no difference in clinical improvement, measured dichotomously (RR 1.14, 95% CI 0.85 to 1.52; 5 studies, 410 participants; low certainty), and may result in better clinical improvement, measured continuously (SMD 0.50, 95% CI 0.22 to 0.78; 7 studies, 387 participants; moderate certainty). Biologics result in better histological improvement (55% higher), measured dichotomously (RR 6.73, 95% CI 2.58 to 17.52; 8 studies, 925 participants; NNTB = 2; moderate certainty). We could not draw conclusions for this outcome when measured continuously (SMD 1.01, 95% CI 0.36 to 1.66; 6 studies, 370 participants; very low certainty). Biologics may result in little to no difference in endoscopic improvement, measured dichotomously (effect not estimable, low certainty). We cannot draw conclusions for this outcome when measured continuously (SMD 2.79, 95% CI 0.36 to 5.22; 1 study, 11 participants; very low certainty). There may be no difference in withdrawals due to adverse events (RR 1.55, 95% CI 0.88 to 2.74; 8 studies, 792 participants; low certainty). AUTHORS' CONCLUSIONS Corticosteroids (as compared to placebo) may lead to clinical symptom improvement when reported both as dichotomous and continuous outcomes, from the primary study definitions. Corticosteroids lead to a large increase in histological improvement (dichotomous outcome) and may increase histological improvement (continuous outcome) when compared to placebo. Corticosteroids may or may not increase endoscopic improvement (depending on whether the outcome is measured dichotomously or continuously). Withdrawals due to adverse events (dichotomous outcome) may occur less frequently when corticosteroids are compared to placebo. Biologics (as compared to placebo) may not lead to clinical symptom improvement when reported as a dichotomous outcome and may lead to an increase in clinical symptom improvement (as a continuous outcome), from the primary study definitions. Biologics lead to a large increase in histological improvement when reported as a dichotomous outcome, but this is uncertain when reported as a continuous outcome, as compared to placebo. Biologics may not increase endoscopic improvement (dichotomous outcome), but this is uncertain when measured as a continuous outcome. Withdrawals due to adverse events as a dichotomous outcome may occur as frequently when biologics are compared to placebo.
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Affiliation(s)
- James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, FL, USA
- College of Medicine, University of Central Florida, Orlando, USA
| | - Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Evan S Dellon
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria and Children's Hospital of Illinois, Peoria, IN, USA
| | - Craig C Reed
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology, University Hospital Puerta de Hierro Majadahonda. Autonomous University of Madrid, Madrid, Spain
| | - Rajitha D Venkatesh
- Pediatrics, Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth A Erwin
- Pediatric Allergy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Abdullah Egiz
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Assem Elleithy
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Edward B Mougey
- Clinical Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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13
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Chang JW, Kliewer K, Haller E, Lynett A, Doerfler B, Katzka DA, Peterson KA, Dellon ES, Gonsalves N. Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:1690-1698. [PMID: 36933603 PMCID: PMC10293042 DOI: 10.1016/j.cgh.2023.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/20/2023]
Abstract
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.
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Affiliation(s)
- Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Emily Haller
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amanda Lynett
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Bethany Doerfler
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University, New York, New York
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah
| | - 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
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Walgraeve S, Vanuytsel T. Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence? Acta Gastroenterol Belg 2023; 86:437-448. [PMID: 37814560 DOI: 10.51821/86.3.11757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Background and study aims Eosinophilic esophagitis (EoE) is a food allergen-induced disease of the esophagus. Chronic, eosinophil-predominant inflammation eventually leads to fibrosis, esophageal dysfunction and severe morbidity. Swallowed topical corticosteroids (STCs) are a mainstay of anti-inflammatory therapy in the treatment of active EoE. Data on the efficacy of novel corticosteroid formulations, developed specifically for esophageal delivery, have recently become available. Methods A comprehensive review was performed aiming to summarize evidence on the role of STCs in the treatment of EoE. Two biomedical bibliographic databases (PubMED, EMBASE) were searched for articles providing original information on the efficacy and safety of STCs in adult EoE patients. Results Budesonide orodispersible tablet (BOT) and budesonide oral suspension (BOS) both surpassed placebo formulations regarding the efficacy of inducing and maintaining histologic, symptomatic and endoscopic remission. Overall, BOT displayed the highest grade of efficacy with clinico-histologic remission rates up to 75% after 1 year. Fluticasone propionate (APT-1011) achieved and maintained histologic and endoscopic responses in the majority of patients, whereas only a positive trend was demonstrated for symptomatic improvement. Mometasone and ciclesonide were studied in a limited number of smaller-scale trials and placebo-controlled data are required to substantiate the promising findings. All STCs displayed a similar side effects profile and were generally considered safe and well-tolerated. Conclusions Current evidence supports long-term treatment with novel corticosteroid formulations, challenging the established treatment paradigm of EoE. BOT appears to be the most effective steroid therapy, although head-to-head comparative trials between STCs are needed.
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Affiliation(s)
- S Walgraeve
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Jamshidi V, Halabian R, Saeedi P, Bagheri H, Nobakht Motlagh Ghoochani BF. Accelerating synergistic effects of preconditioned mesenchymal stem cells with Crocin and dexamethasone in pulmonary epithelial cells injury. Toxicol Res (Camb) 2023; 12:369-380. [PMID: 37397913 PMCID: PMC10311171 DOI: 10.1093/toxres/tfad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/14/2023] [Accepted: 03/19/2023] [Indexed: 07/04/2023] Open
Abstract
Chemical warfare victims suffer from bronchiolitis and chronic pulmonary obstruction caused by sulfur mustard (SM) toxicity. Despite the mesenchymal stem cells capacity to alleviate inflammation, their low survival rate under oxidative stress severely limits their effectiveness. This study aimed to examine how natural (Crocin) and synthetic (Dexamethasone) antioxidants might affect MSC efficacy. MSCs were treated with the optimal doses of Crocin (Cr.), Dexamethasone (Dex.), and their combination. The A549 cells line was pretreated with the optimal dose of the CEES to mimic the lung disease. Then, the affected A549 cells were exposed to the preconditioned MSCs and conditioned media, and then their survival rates were estimated by MTTor2,5-diphenyl-2H-tetrazolium bromide (MTT) assay. Annexin-V PI apoptosis test was conducted for MSCs and A549 cells. Reactive Oxygen Species (ROS) assay and Enzyme-linked immunosorbent assay (ELISA) test demonstrated the percentage of production of ROS and the cytokines levels in A549/CEES, respectively. The results revealed significant increases in Cr. + Dex. treated MSCs (P < .01) and A549 cells treated with MSCs-CM/Cr/Dex (P < .01) groups' survival. The apoptosis rate and ROS production were reduced in the MSCs-CM/Cr/Dex. Also, considerable decreases in IL-1β (P < .01) and IL-6 (P < .01) and a significant increase in IL-10 (P < .05) in treated A549/CEES by Cr/Dex and MSCs-CM/Cr/Dex supported the synergistic effects of Crocin and Dexamethasone.
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Affiliation(s)
- Vahid Jamshidi
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 14359-44711, Iran
| | - Raheleh Halabian
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 14359-44711, Iran
| | - Pardis Saeedi
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 14359-44711, Iran
| | - Hasan Bagheri
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 14359-44711, Iran
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Miehlke S, Arnim UV, Schlag C, Labenz J, Madisch A. [Treatment of eosinophilic esophagitis - advancements and perspectives]. Laryngorhinootologie 2023; 102:339-348. [PMID: 37141876 DOI: 10.1055/a-1861-7152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Stephan Miehlke
- Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Hamburg, Germany
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious diseases, Universitätsklinikum Magdeburg AöR, Magdeburg, Germany
| | - Christoph Schlag
- Second medical department, Klinikum rechts der Isar der Technischen Universität München, Munchen, Germany
| | - Joachim Labenz
- Medizinische Klinik, Ev. Jung-Stilling Krankenhaus, Siegen, Germany
| | - Ahmed Madisch
- Department of Internal Medicine, Siloah Hospital, Hannover, Germany
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Hirano I, Dellon ES, Gupta SK, Katzka DA, Collins MH, Wojtowicz AM, Terreri B, Zhang W, Boules M, Bhatia S, Desai NK. Safety of an investigational formulation of budesonide (budesonide oral suspension) for eosinophilic oesophagitis: an integrated safety analysis of six phase 1-3 clinical trials. Aliment Pharmacol Ther 2023; 57:1117-1130. [PMID: 36890134 DOI: 10.1111/apt.17430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/05/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Questions remain regarding the safety of swallowed topical corticosteroids in eosinophilic oesophagitis (EoE). AIM To assess the safety of an investigational formulation of budesonide (budesonide oral suspension; BOS) from six trials. METHODS Safety data were integrated from six trials (healthy adults: SHP621-101 [phase 1]; patients with EoE: MPI 101-01 and MPI 101-06 [phase 2]; SHP621-301, SHP621-302 and SHP621-303 [phase 3]) for participants who received ≥1 dose of study drug (BOS 2.0 mg twice daily [b.i.d.], BOS any dose [including BOS 2.0 mg b.i.d.] and placebo). Adverse events (AEs), laboratory testing, bone density and adrenal AEs were assessed. Exposure-adjusted incidence rates were calculated for AEs and AEs of special interest (AESIs). RESULTS Overall, 514 unique participants were included (BOS 2.0 mg b.i.d., n = 292; BOS any dose, n = 448; placebo, n = 168). The BOS 2.0 mg b.i.d., BOS any dose and placebo groups totalled 93.7, 122.4 and 25.0 participant-years of exposure (PY), respectively. Proportions of treatment-emergent AEs (TEAEs) and AESIs (any) reported were higher for BOS than placebo; however, most were mild/moderate in severity. The most commonly reported AESIs (exposure-adjusted incidence rates [per 100 PY]) in the BOS 2.0 mg b.i.d., BOS any dose and placebo groups were infections (133.5, 154.4 and 136.2, respectively) and gastrointestinal AEs (84.3, 80.9 and 92.1, respectively). Adrenal AEs were more frequent with BOS 2.0 mg b.i.d. and BOS any dose than placebo (44.8, 34.3 and 24.0, respectively). TEAEs and AESIs related to study drug or leading to discontinuation were infrequent. CONCLUSIONS BOS was well-tolerated; most TEAEs with BOS were mild/moderate in severity. CLINICALTRIALS GOV NUMBERS SHP621-101 (no clinical trials registration number), MPI 101-01 (NCT00762073), MPI 101-06 (NCT01642212), SHP621-301 (NCT02605837), SHP621-302 (NCT02736409) and SHP621-303 (NCT03245840).
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Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA.,Community Health Network, Indianapolis, Indiana, USA
| | - David A Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Brian Terreri
- Takeda Pharmaceuticals USA, Inc., Lexington, Massachusetts, USA
| | - Wenwen Zhang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Mena Boules
- Takeda Pharmaceuticals USA, Inc., Lexington, Massachusetts, USA
| | - Siddharth Bhatia
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts, USA
| | - Nirav K Desai
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
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Schupack DA, Johnson K, Akambase JA, Geno D, Lavey C, Lennon RJ, Ravi K, Snyder DL, Katzka DA, Alexander JA. Histologic response to steroids in eosinophilic esophagitis is dependent on delivery compound. Dis Esophagus 2022; 36:6627605. [PMID: 35780320 DOI: 10.1093/dote/doac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/04/2022] [Accepted: 05/30/2022] [Indexed: 01/11/2023]
Abstract
Topical steroids are commonly used in treatment of eosinophilic esophagitis (EoE), but currently there is lack of data to clarify most effective regimen. We aimed to study the achievement of histologic remission using the same dose of budesonide in two different delivery formulations. Patients with established EoE treated with pharmacy compounded budesonide capsule or budesonide Rincinol gel (both 3 mg twice daily) were studied retrospectively. Those with pre-treatment and post-treatment histologic assessment were included with main endpoint being histologic remission. 103 patients (62 gel, 41 capsule) were included, with higher rate of histologic remission with gel (84 vs. 59%, P=0.004). A subset of patients in both groups had lack of steroid response (<50% drop in eosinophils) (15% for gel, 32% for capsule). Formulation/delivery vehicle of steroid treatments to esophageal mucosa in EoE appears important for treatment efficacy, with budesonide gel having higher likelihood of histologic remission compared to budesonide capsules in our population. A truly steroid refractory group appears likely in our population. Larger, prospective studies may help clarify best regimen of topical steroids in EoE and may work to identify patients likely to benefit from alternative therapies.
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Affiliation(s)
- Daniel A Schupack
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph A Akambase
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Debra Geno
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Crystal Lavey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Diana L Snyder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Liu X, Xiao X, Liu D, Tan C. A meta-analysis on randomized controlled trials of treating eosinophilic esophagitis with budesonide. Ann Med 2022; 54:2078-2088. [PMID: 35862288 PMCID: PMC9310820 DOI: 10.1080/07853890.2022.2101689] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a chronic, local immune-mediated inflammatory oesophageal disease. Although Budesonide is recommended as one of the first-line drugs for EoE treatment, its efficacy is still controversial in multiple studies. Due to the continuous emergence of new and reliable research evidence in recent years, we updated the meta-analysis using RCT trial results to evaluate the efficacy and safety of budesonide. MATERIALS AND METHOD Retrieve the data of the randomised controlled trial literature from 2000 to June 20, 2021, on using Budesonide in the treatment of eosinophilic esophagitis from the three major databases. Based on the results achieved with the Cochrane risk assessment tool, evaluate the quality of the included literature to extract the data, and perform the Meta-analysis with RevMan5.4 and Stata15.0. RESULTS A total of 958 articles were retrieved, with 10 articles finally included, thus forming a sample size of 712 cases. The main outcome indicators of the meta-analysis are as follows: (1) Histological remission: the Budesonide group performs better than the placebo control group when it comes to histological remission of injuries [RR = 23.82, 95%CI = (13.46, 42.21), p < .001]; (2) Eosinophil count: the Budesonide group is superior to the control group in terms of reduced eosinophil count [SMD = -1.34, 95%CI = (-1.52, -1.15), p < .001]. CONCLUSION More and more high-quality randomised controlled trials show that oral budesonide in the treatment of eosinophils esophagitis was better than the placebo group. Mounting high-quality RCTs have confirmed the efficacy of oral budesonide in the treatment of eosinophilic esophagitis and that the effects of this drug may not be so dose-dependent. It is safe to take budesonide for a long time, and this drug is a relatively ideal option for drug treatment of eosinophilic esophagitis at present, so it is worthy of clinical application.Key MessagesWe used high-quality randomised controlled trials to meta-update the previous results to further confirm the clinical efficacy and safety of budesonide.Oral budesonide in the treatment of eosinophilic esophagitis is significantly better than the placebo control group. We have confirmed the value of its clinical application and promotion by including more high-quality randomised controlled trials.We also found that the efficacy of budesonide in patients is not dose-dependent, and more research is needed to confirm this.
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Affiliation(s)
- Xiaopei Liu
- School of Basic Medicine, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Xue Xiao
- School of Basic Medicine, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Dan Liu
- Department of Anorectal, Xi'an Hospital of Traditional Chinese Medicine, Xi'an, Shaanxi, China
| | - Cong'e Tan
- School of Basic Medicine, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
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20
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A New Viscous Budesonide Formulation for the Treatment of Eosinophilic Esophagitis in Children: A Preliminary Experience and Review of the Literature. J Clin Med 2022; 11:jcm11226730. [PMID: 36431208 PMCID: PMC9694526 DOI: 10.3390/jcm11226730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic disease, characterized clinically by esophageal disfunction. Topical corticosteroids (tCS), predominantly fluticasone and budesonide, are considered the effective first line treatment, as well as an option of maintenance therapy in EoE. The way that tCS are administered significantly affects their effectiveness. There is still no ready-to-use steroid drug to be applied topically to the esophagus in children-a few experimental viscous slurries (mainly of budesonide) have been shown in trials to be more effective than steroids administered via metered dose inhalers (MDIs) and swallowed. The best examined steroid solvent of all is sucralose, a high-intensity artificial sweetener. Although it has been shown in a critical review that it is non-toxic and safe for all consumers, there are still some concerns among patients about its potential adverse effect on humans. Due to that fact, we developed a new viscous formulation and evaluated its effectiveness in the treatment of children with EoE. In an open, prospective, single-center study, we administered our new formulation of viscous budesonide twice daily for 8 weeks in patients with an active EoE. After treatment, we performed a control gastroscopy with the collection and evaluation of histopathological samples. We have proven our formulation effectiveness at 64%, as far as histological remission is concerned. We have also shown a reduction in the mean endoscopic reference score (EREFS) from 3.1 points at the beginning of the study to 1.6 points at the end of the study. Bearing in mind how important the acceptance of the solvent is for long-time compliance, especially among children, we also decided to assess the taste of the formulation. Therefore, we asked 46 adults and 10 children to swallow a sample of the solvent and fill in a short anonymous questionnaire about its taste, smell, consistency and easiness of swallowing. General acceptance for the proprietary solvent was high, reaching 7.5/10 among adults and 6.5/10 in children. To be able to compare the results of our preliminary experience, we reviewed the studies which evaluated substances that have been used so far as steroid solvents for the treatment of EoE. The overall effectiveness of the oral viscous budesonide (OVB) ranged from 65% to 90%, which is consistent with the results obtained in our study. Unfortunately, the high heterogeneity of the studies did not allow us to draw reliable conclusions.
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21
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Decker A, Schauer F, Lazaro A, Monasterio C, Schmidt AR, Schmitt-Graeff A, Kreisel W. Esophageal lichen planus: Current knowledge, challenges and future perspectives. World J Gastroenterol 2022; 28:5893-5909. [PMID: 36405107 PMCID: PMC9669830 DOI: 10.3748/wjg.v28.i41.5893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/17/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.
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Affiliation(s)
- Annegrit Decker
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Franziska Schauer
- Department of Dermatology, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79104, Germany
| | - Adhara Lazaro
- Department of Medicine, Institute of Exercise and Occupational Medicine, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg 79106, Germany
| | - Carmen Monasterio
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Arthur Robert Schmidt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
| | - Annette Schmitt-Graeff
- Institute for Dermatohistology, Pathology, and Molecular Pathology Prof. Dr. Laaf, Freiburg, Germany and: University of Freiburg, Freiburg 79106, Germany
| | - Wolfgang Kreisel
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg 79106, Germany
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22
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Dellon ES, Lucendo AJ, Schlag C, Schoepfer AM, Falk GW, Eagle G, Nezamis J, Comer GM, Knoop K, Hirano I. Fluticasone Propionate Orally Disintegrating Tablet (APT-1011) for Eosinophilic Esophagitis: Randomized Controlled Trial. Clin Gastroenterol Hepatol 2022; 20:2485-2494.e15. [PMID: 35181572 DOI: 10.1016/j.cgh.2022.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Topical steroids are effective treatments for eosinophilic esophagitis (EoE). The FLUTE (Fluticasone in EoE) trial evaluated safety and efficacy of APT-1011 (fluticasone propionate oral disintegrating tablet) vs placebo for treatment of EoE. METHODS In this randomized, double-blind, placebo-controlled, dose-finding, phase 2b trial, 106 adults with EoE received 1 of 4 APT-1011 doses or placebo for a 12-week induction period and 40 weeks of maintenance. Primary outcome was histologic response (≤6 eosinophils per high-power field) at Week 12. Secondary outcomes included endoscopic features and dysphagia frequency. RESULTS Histologic response rates were 0% for placebo, 80% for APT-1011 3 mg twice daily (BID), 67% for 3 mg at bedtime (HS), 86% for 1.5 mg BID, 48% for 1.5 mg HS (P < .001 for all groups vs placebo). At Week 12, mean Edema/Rings/Exudates/Furrows/Strictures (EoE Endoscopic Reference Score) total score (max, 9.0) improved from 4.5 to 2.3 for 3 mg BID, 5.3 to 2.1 for 3 mg HS, 4.6 to 1.7 for 1.5 mg BID, 5.3 to 2.9 for 1.5 mg HS vs 5.2 to 4.5 for placebo. Mean dysphagia frequency over 14 days improved from baseline to Week 12 with all active groups improving more than placebo. Improvements were sustained to Week 52. APT-1011 was safe and well-tolerated, with higher incidence of candidiasis noted at the higher twice daily doses. CONCLUSION APT-1011 dosing regimens were superior for histologic and endoscopic responses, and for reduction in dysphagia frequency vs placebo. Based on the symptom improvement and assessment of adverse events together with the histologic response rate, 3 mg once daily at bedtime dose showed the most favorable risk-benefit profile. CLINICALTRIALS gov, Number: NCT03191864.
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Affiliation(s)
- 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.
| | - Alfredo J Lucendo
- Division of Gastroenterology, General Hospital Tomelloso, Ciudad Real, Spain
| | - Christoph Schlag
- Second Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gina Eagle
- Ellodi Pharmaceuticals, Lawrenceville, New Jersey
| | | | - Gail M Comer
- Ellodi Pharmaceuticals, Lawrenceville, New Jersey
| | - Karol Knoop
- Ellodi Pharmaceuticals, Lawrenceville, New Jersey
| | - Ikuo Hirano
- Department of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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23
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Thakkar KP, Fowler M, Keene S, Iuga A, Dellon ES. Long-term efficacy of proton pump inhibitors as a treatment modality for eosinophilic esophagitis. Dig Liver Dis 2022; 54:1179-1185. [PMID: 35410852 PMCID: PMC9427674 DOI: 10.1016/j.dld.2022.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are a first-line treatment for EoE, but data are limited concerning response durability. We aimed to determine long-term outcomes in EoE patients responsive to PPI-therapy. METHODS We conducted a retrospective cohort study of newly diagnosed adults with EoE who had initial histologic response (<15 eosinophils per high-power-field) to PPI-only therapy. We extracted data regarding their subsequent clinical course and outcomes. We compared findings between the initial PPI-response endoscopy and the final endoscopy, and assessed factors associated with loss of PPI response. RESULTS Of 138 EoE patients with initial histologic response to PPI, 50 had long-term endoscopic follow-up, 40 had clinical follow-up, 10 changed treatments, and 38 had no long-term follow-up. Of those with endoscopic follow-up, mean follow-up-time was 3.6 ± 2.9 years; 30 and 32 patients (60%; 64%) maintained histologic and symptom responses, respectively. However, fibrotic endoscopic findings of EoE were unchanged. Younger age (aOR 1.05, 95% CI: 1.01-1.11) and dilation prior to PPI treatment (aOR 0.21, 95% CI: 0.05-0.83) were the only factors associated with long-term loss of PPI response. CONCLUSIONS Long-term histologic and clinical response rates for PPI therapy were 60% and 64%, respectively. Younger age and dilation at baseline were associated with histologic loss of response. These data can inform long-term EoE treatment selection.
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Affiliation(s)
- Kisan P Thakkar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB#7080 Bioinformatics Building, 130 Mason Farm Rd. UNC-CH, Chapel Hill, NC 27599-7080, USA
| | - Mark Fowler
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Staci Keene
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alina Iuga
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB#7080 Bioinformatics Building, 130 Mason Farm Rd. UNC-CH, Chapel Hill, NC 27599-7080, USA; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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24
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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25
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Cotton CC, Woosley JT, Moist SE, McGee SJ, Iuga A, Shaheen NJ, Dellon ES. Determination of a treatment response threshold for the Eosinophilic Esophagitis Endoscopic Reference Score. Endoscopy 2022; 54:635-643. [PMID: 34674209 DOI: 10.1055/a-1675-7860] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic features of eosinophilic esophagitis (EoE) are measured using the validated EoE Endoscopic Reference Score (EREFS); however, a threshold for treatment response has not been defined. We aimed to determine a cut-point for endoscopic response as measured by EREFS. METHODS We performed a secondary analysis of a randomized clinical trial comparing budesonide slurry with swallowed fluticasone multidose inhaler for initial treatment of EoE. In the parent trial, EREFS was determined before and after treatment (score range 0-9), as were histologic findings and dysphagia symptoms. We performed tabular, flexible trend, and dependent mixture analyses of measures of treatment response to select the best clinical EREFS threshold. RESULTS In the 111 included patients (mean age 39 years; 67 % male; 96 % white), an EREFS threshold of ≤ 2 was 80 % sensitive (95 % confidence interval [CI] 69 % to 88 %) and 83 % specific (95 %CI 67 % to 94 %) for histologic response (peak of < 15 eosinophils per high-power field). Flexible trend analysis and dependent mixture modeling similarly suggested that a threshold of ≤ 2 best captured the correlation of EREFS with histologic and symptomatic measures. Dependent mixture modeling found near-total membership in the response class at EREFS of 0 or 1 and > 75 % at EREFS of 2 or 3. CONCLUSIONS An EREFS of ≤ 2 was the best clinical threshold for endoscopic response to topical steroid treatment, and was consistent with clinical and histologic response. Therefore, future studies can report a binary outcome of endoscopic response when EREFS is 2 or less.
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Affiliation(s)
- Cary C Cotton
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina, United States
| | - John T Woosley
- University of North Carolina at Chapel Hill, Department of Pathology and Laboratory Medicine, Chapel Hill, North Carolina, United States
| | - Susan E Moist
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina, United States
| | - Sarah J McGee
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina, United States
| | - Alina Iuga
- University of North Carolina at Chapel Hill, Department of Pathology and Laboratory Medicine, Chapel Hill, North Carolina, United States
| | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina, United States
| | - Evan S Dellon
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Chapel Hill, North Carolina, United States
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26
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Dellon ES, Collins MH, Katzka DA, Mukkada VA, Falk GW, Morey R, Goodwin B, Eisner JD, Lan L, Desai NK, Williams J, Hirano I. Long-Term Treatment of Eosinophilic Esophagitis With Budesonide Oral Suspension. Clin Gastroenterol Hepatol 2022; 20:1488-1498.e11. [PMID: 34182150 DOI: 10.1016/j.cgh.2021.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/04/2021] [Accepted: 06/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS We evaluated treatment withdrawal, long-term outcomes, and safety of budesonide oral suspension (BOS) 2.0 mg twice daily in patients with eosinophilic esophagitis who completed a 12-week induction study. METHODS Induction full responders (≤6 eosinophils per high-power field [eos/hpf] and ≥30% reduction in the Dysphagia Symptom Questionnaire score) to BOS 2.0 mg twice daily (ORBIT1/SHP621-301/NCT02605837) were randomized to continue BOS (BOS-BOS) or withdraw to placebo (BOS-PBO) for 36 weeks (ORBIT2/SHP621-302/NCT02736409). Induction partial responders and nonresponders, and patients who received induction placebo, received BOS for 36 weeks. The primary end point was the proportion of BOS-BOS and BOS-PBO patients who relapsed (≥15 eos/hpf and ≥4 days of dysphagia [Dysphagia Symptom Questionnaire] over 2 weeks) by week 36. The key secondary end point was the proportion of induction partial responders and nonresponders who fully responded after 52 weeks of total BOS therapy. Other secondary end points included the proportion of induction full responders with histologic responses (≤1, ≤6, <15 eos/hpf) at week 12 of the extension study, and safety outcomes. RESULTS The randomized withdrawal period enrolled 48 patients (BOS-BOS, n = 25; BOS-PBO, n = 23); 106 induction partial responders and nonresponders, and 65 induction placebo patients received BOS. More BOS-PBO than BOS-BOS patients relapsed over 36 weeks (43.5% vs 24.0%; P = .131) and had histologic responses at week 12 of therapy (P < .001). Overall, 13.2% of induction partial responders and nonresponders fully responded at week 36. BOS was well tolerated; therapy duration was not associated with new safety concerns. CONCLUSIONS For induction full responders, continuing BOS numerically improved maintenance of efficacy vs withdrawal. A longer therapy duration did not raise safety concerns. (ClinicalTrials.gov: NCT02736409.).
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin Morey
- Takeda Development Center Americas, Inc, Lexington, Massachusetts
| | - Bridgett Goodwin
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts
| | | | - Lan Lan
- Takeda Development Center Americas, Inc, Lexington, Massachusetts
| | - Nirav K Desai
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts
| | - James Williams
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Spergel BL, Ruffner MA, Godwin BC, Liacouras CA, Cianferoni A, Gober L, Hill DA, Brown-Whitehorn TF, Chaiboonma K, Aceves SA, Muir AM, Spergel JM. Improvement in eosinophilic esophagitis when using dupilumab for other indications or compassionate use. Ann Allergy Asthma Immunol 2022; 128:589-593. [PMID: 35085819 DOI: 10.1016/j.anai.2022.01.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dupilumab has been approved to treat atopic dermatitis, asthma, and nasal polyps and is in active clinical trials for the treatment of eosinophilic esophagitis (EoE). Given its shared immunopathology, we hypothesized that EoE symptoms and inflammation would improve when dupilumab therapy was used for other allergic indications. OBJECTIVE To measure the clinical and histologic response in EoE to dupilumab when treating other atopic diseases. METHODS We completed a retrospective chart review of all patients at Children's Hospital of Philadelphia and Rady Children Hospital who were prescribed dupilumab for atopic dermatitis, asthma, or nasal polyps and had a concomitant clinical diagnosis of EoE. Demographic information along with histology, symptom scores, medications, and diet information were collected. Response to dupilumab was evaluated. RESULTS A total of 45 patients were identified. Of which, 11 patients were prescribed dupilumab for asthma, 27 for atopic dermatitis, 3 for nasal polyps, and 4 for compassionate use for EoE. There was no follow-up data for 8 patients. Follow-up histology was available for 26 patients: 22 of 26 had less than 6 eosinophils per high power field after the initiation of dupilumab with significant improvement (pre: 52.9 + 35.1 to post: 4.5 + 10.9 eosinophils/high power field, P < .005). A total of 28 patients had improvement of symptoms, with 24 patients reporting complete resolution of symptoms after dupilumab initiation. Reductions in EoE treatment medications (swallowed steroids, proton pump inhibitors) or expansion of diet occurred in 29 patients treated with dupilumab. CONCLUSION Dupilumab therapy initiated for atopic disease effectively induces symptomatic and histologic remission of esophageal disease and reduces the need for EoE-directed therapy in patients with concomitant EoE.
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Affiliation(s)
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bridget C Godwin
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Gober
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Hill
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri F Brown-Whitehorn
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kira Chaiboonma
- Division of Allergy and Immunology, Rady Children's Hospital San Diego, University of California at San Diego, San Diego, California
| | - Seema A Aceves
- Division of Allergy and Immunology, Rady Children's Hospital San Diego, University of California at San Diego, San Diego, California
| | - Amanda M Muir
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania.
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Older patients with eosinophilic esophagitis have high treatment response to topical steroids. Dig Liver Dis 2022; 54:477-482. [PMID: 34789398 PMCID: PMC8967778 DOI: 10.1016/j.dld.2021.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/11/2022]
Abstract
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.
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Development and Validation of Web-Based Tool to Predict Lamina Propria Fibrosis in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:272-279. [PMID: 34932022 PMCID: PMC8858426 DOI: 10.14309/ajg.0000000000001587] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Approximately half of esophageal biopsies from patients with eosinophilic esophagitis (EoE) contain inadequate lamina propria, making it impossible to determine the lamina propria fibrosis (LPF). This study aimed to develop and validate a web-based tool to predict LPF in esophageal biopsies with inadequate lamina propria. METHODS Prospectively collected demographic and clinical data and scores for 7 relevant EoE histology scoring system epithelial features from patients with EoE participating in the Consortium of Eosinophilic Gastrointestinal Disease Researchers observational study were used to build the models. Using the least absolute shrinkage and selection operator method, variables strongly associated with LPF were identified. Logistic regression was used to develop models to predict grade and stage of LPF. The grade model was validated using an independent data set. RESULTS Of 284 patients in the discovery data set, median age (quartiles) was 16 (8-31) years, 68.7% were male patients, and 93.4% were White. Age of the patient, basal zone hyperplasia, dyskeratotic epithelial cells, and surface epithelial alteration were associated with presence of LPF. The area under the receiver operating characteristic curve for the grade model was 0.84 (95% confidence interval: 0.80-0.89) and for stage model was 0.79 (95% confidence interval: 0.74-0.84). Our grade model had 82% accuracy in predicting the presence of LPF in an external validation data set. DISCUSSION We developed parsimonious models (grade and stage) to predict presence of LPF in esophageal biopsies with inadequate lamina propria and validated our grade model. Our predictive models can be easily used in the clinical setting to include LPF in clinical decisions and determine its effect on treatment outcomes.
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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Treatment of Eosinophilic Esophagitis: Diet or Medication? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3249-3256. [DOI: 10.1016/j.jaip.2021.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022]
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Miehlke S, von Arnim U, Schlag C, Labenz J, Madisch A. [Treatment of eosinophilic esophagitis - advancements and perspectives]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:869-878. [PMID: 34157757 DOI: 10.1055/a-1429-4192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Stephan Miehlke
- Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Hamburg
- Speiseröhrenzentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Ulrike von Arnim
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg
| | - Christoph Schlag
- Medizinische Klinik II, Klinikum Rechts der Isar, Technische Universität, München
| | - Joachim Labenz
- Klinik für Innere Medizin, Diakonie Klinikum Jung-Stilling, Siegen
| | - Ahmed Madisch
- Klinik für Gastroenterologie, KRH Klinikum Siloah, Hannover
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Dellon ES, Collins MH, Katzka DA, Hudgens S, Lan L, Williams J, Vera-Llonch M, Hirano I. Improvements in Dysphagia and Pain With Swallowing in Patients With Eosinophilic Esophagitis Receiving Budesonide Oral Suspension. Clin Gastroenterol Hepatol 2021; 19:699-706.e4. [PMID: 32272243 DOI: 10.1016/j.cgh.2020.03.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/28/2020] [Accepted: 03/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Quantification of eosinophilic esophagitis (EoE) symptoms is crucial for assessing treatment outcomes. We aimed to explore the effect of budesonide oral suspension (BOS) on dysphagia and pain with swallowing. METHODS We performed a secondary analysis of data from a phase 2 multicenter, double-blind, trial (conducted from July 2012 through October 2014) of patients with EoE, 11-40 y old, who were randomly assigned to groups given placebo or BOS (2.0 mg twice daily) for 12 weeks. Symptoms were quantified using the Dysphagia Symptom Questionnaire (DSQ) from baseline to week 12 of therapy. RESULTS Overall, 93 patients were randomly assigned to groups; the prespecified modified intention-to-treat analysis set comprised 87 patients (38 from the placebo group and 49 from the BOS group). Improvements from baseline in least-squares mean (standard error) DSQ (Q2+Q3) scores were observed. The difference between groups was statistically significant only at week 12 (placebo vs BOS: week 4, -4.9 [1.7] vs -7.4 [1.5]; P = .265; week 8, -7.4 [2.1] vs -10.3 [1.8]; P = .288; week 12, -7.5 [1.9] vs -14.3 [1.7]; P = .01). Similar findings were observed for pain (Q4) scores (placebo vs BOS: week 4, -2.5 [0.8] vs -3.3 [0.7]; P = .484; week 8, -3.0 [0.8] vs -4.9 [0.7]; P = .066; week 12, -3.1 [0.8] vs -4.9 [0.7]; P = .109). More severe DSQ and DSQ+pain scores were associated with presence of other symptoms (such as regurgitation) and physician-rated severity. Improvements in DSQ and DSQ+pain scores were greater in patients with either a histologic or endoscopic response than in patients without a response. CONCLUSIONS In a secondary analysis of data from a phase 2 trial of patients with EoE, we found evidence for improvements in dysphagia and pain scores in patients who received BOS (2.0 mg twice daily) vs placebo. Pain with swallowing should be considered in the clinical assessment of patients with EoE. ClinicalTrials.gov no: NCT01642212.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Lan Lan
- Shire, a Takeda company, Lexington, Massachusetts
| | | | | | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kim SJ, Park MI, Kim GH, Lee MW, Jung K, Lee J, Seol SY, Jee SR, Lee HS, Jang JS, Cha JH. Practice Patterns for Eosinophilic Esophagitis Patients in Busan and Gyeongnam: A Korean Multicenter Database Study. J Neurogastroenterol Motil 2021; 27:71-77. [PMID: 32699187 PMCID: PMC7786091 DOI: 10.5056/jnm20069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Background/Aims The prevalence of eosinophilic esophagitis is increasing in Korea and there are few single-center studies regarding eosinophilic esophagitis in Korea. In particular, data about management for eosinophilic esophagitis are lacking. We aim to evaluate the practice patterns, including initial treatment and response, in the Busan city and Gyeongnam province area. Methods We retrospectively reviewed medical records to gain data on patient characteristics, medication, endoscopic images, and esophageal biopsy results. From January 2009 to December 2019, a total of 42 patients were diagnosed with eosinophilic esophagitis. Results The mean age was 50.7 (from 22 to 81) years and the cohort was predominantly male (78.6%, 33/42). The proton pump inhibitor was the preferred treatment as an initial trial for 64.3% (27/42) of patients, followed by swallowed topical steroids (16.7%, 7/42). Clinical improvement after proton pump inhibitor therapy was achieved in 88.9% (24/27) of patients. Two patients who did not achieve improvement showed a clinical and endoscopic response after swallowed topical steroids treatment. No patient received diet elimination or balloon dilatation therapy. Conclusions The treatment response of eosinophilic esophagitis was good in Busan city and Gyeongnam province area in Korea. Proton pump inhibitor therapy was the preferred and most effective treatment for eosinophilic esophagitis as the initial therapy.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jin Lee
- Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
| | - Sang Young Seol
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Sam Ryong Jee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Jin Seok Jang
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jae Hwang Cha
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
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Ketchem CJ, Reed CC, Stefanadis Z, Dellon ES. Treatment with compounded fluticasone suspension improves the clinical, endoscopic, and histologic features of eosinophilic esophagitis. Dis Esophagus 2020; 34:6031239. [PMID: 33306783 PMCID: PMC8275977 DOI: 10.1093/dote/doaa120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Corey J Ketchem
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Craig C Reed
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Evan S Dellon
- Address correspondence to: Evan S. Dellon MD, MPH, CB#7080 Bioinformatics Building, 130 Mason Farm Rd. UNC-CH, Chapel Hill, NC 27599-7080, USA. Tel: (919) 966-2513; Fax: (919) 843-2508;
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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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Munoz-Osores E, Maldonado-Campos I, Olivares-Labbe MT, Villarroel L, Gana JC. Corticosteroids for Eosinophilic Esophagitis in Children: A Meta-analysis. Pediatrics 2020; 146:peds.2020-0874. [PMID: 33115796 DOI: 10.1542/peds.2020-0874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Treatment of eosinophilic esophagitis (EoE) is focused on dietary, pharmacologic, and endoscopic therapy options. Within the pharmacologic alternatives, topical corticosteroids are the most used, and a large number of studies evaluating their effectiveness have been published, requiring a new summary of evidence. OBJECTIVE To evaluate the histologic and clinical effectiveness of the use of corticosteroids in pediatric patients with a diagnosis of EoE. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, Latin American and Caribbean Health Sciences Literature, and ClinicalTrials.gov (June 2019). STUDY SELECTION We selected randomized controlled trials assessing corticosteroids versus a placebo or dietary treatment of EoE in children. DATA EXTRACTION Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system. The primary outcomes were clinical and histologic improvement. RESULTS A total of 1655 studies were identified. Five studies were included (206 patients). Histologic response was 49.25% in the corticosteroids group and 4.16% in the placebo group (risk ratio 11.05 [confidence interval 3.8-32.15]; P < .0001). Symptomatic response was 33.6% in the corticosteroids group and 21.8% in the control group (risk ratio 1.62 [confidence interval 0.94-2.79]; P = .08). There were no major adverse effects. LIMITATIONS Heterogeneity of the diagnosis of EoE. CONCLUSIONS Our review revealed favorable results of corticosteroids versus placebo, mainly in histologic response. More studies are needed, by using validated clinical scores, to obtain more reliable results.
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Affiliation(s)
| | | | | | | | - J C Gana
- Division of Pediatrics, .,Department of Gastroenterology and Nutrition, Escuela de Medicina, and
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Nennstiel S, Schlag C. Treatment of eosinophlic esophagitis with swallowed topical corticosteroids. World J Gastroenterol 2020; 26:5395-5407. [PMID: 33024392 PMCID: PMC7520613 DOI: 10.3748/wjg.v26.i36.5395] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/09/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic local immune-mediated disease of the esophagus. Beside proton pump inhibitors and food-restriction-diets swallowed topical corticosteroids (STC) can be offered as a first line therapy according to current guidelines. This review describes the background and practical management of STCs in EoE. So far, mainly asthma inhalers containing either budesonide or fluticasone have been administered to the esophagus by swallowing these medications “off label”. Recently esophagus-targeted formulations of topical steroids have been developed showing clinicopathological response rates up to 85% - an orodispersible tablet of budesonide has been approved as the first “in label” medication for EoE in Europe in June 2018. Whereas it was shown that disease remission induction of EoE by STCs is highly effective, there is still a lack of data regarding long-term and maintenance therapy. However, current studies on STC maintenance therapy add some movement into the game.
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Affiliation(s)
- Simon Nennstiel
- Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für Innere Medizin II, Munich 81675, Germany
| | - Christoph Schlag
- Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für Innere Medizin II, Munich 81675, Germany
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Jayakrishnan T, Babu M, Goodnow S, Hardman B. BUDESONIDE-INDUCED HYPEROSMOLAR HYPERGLYCEMIC STATE FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT. AACE Clin Case Rep 2020; 6:e265-e268. [PMID: 32984535 DOI: 10.4158/accr-2020-0216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/13/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Recognize a rare endocrinological side effect of a drug, budesonide, which surfaced as a result of a major procedure. METHODS We describe a patient who presented with hyperglycemic hyperosmolar state (HHS) likely as a result of the bypass of first-pass metabolism due to budesonide treatment after a transjugular intrahepatic portosystemic shunt (TIPS) procedure. RESULTS A 62-year-old female with history of combined variable immunodeficiency complicated by colitis (managed by 9 mg budesonide by mouth daily) and refractory ascites secondary to non-cirrhotic portal hypertension (status post-TIPS 3 weeks prior) presented to the hospital with HHS. Her initial insulin requirements were high but improved after discontinuation of budesonide. She was able to be transitioned to a sliding scale and discharged on metformin. When taken orally, budesonide is subject to high first-pass metabolism resulting in minimal systemic effects. Development of HHS and dramatic insulin requirements within 3 weeks of TIPS with drastic improvement following the discontinuation of budesonide leads us to postulate that this was bypassed, leading to steroid-induced diabetes. CONCLUSION The case beckons us to be mindful of procedures that alter drug metabolism and make necessary adjustments to prevent complications.
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Affiliation(s)
- Thejus Jayakrishnan
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Meera Babu
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Steven Goodnow
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Brent Hardman
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Collins MH, Dellon ES, Katzka DA, Hirano I, Williams J, Lan L. Budesonide Oral Suspension Significantly Improves Eosinophilic Esophagitis Histology Scoring System Results: Analyses From a 12-Week, Phase 2, Randomized, Placebo-controlled Trial. Am J Surg Pathol 2020; 43:1501-1509. [PMID: 31498177 DOI: 10.1097/pas.0000000000001361] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Budesonide oral suspension (BOS) is a novel topical corticosteroid, which has been shown to improve symptoms and endoscopic appearance, and reduce peak eosinophil counts in patients with eosinophilic esophagitis (EoE). This trial evaluated the effect of BOS or placebo on the severity (grade) and extent (stage) of 8 histopathologic features observed in EoE, using the validated eosinophilic esophagitis histologic scoring system (EoE HSS). Patients with EoE aged 11 to 40 years with dysphagia were randomized to receive either BOS (2.0 mg twice daily) or placebo for 12 weeks. Mean (SD) EoE HSS grade and stage total scores at baseline for placebo and BOS groups were: grade, 0.42 (0.16) and 0.49 (0.14), respectively; stage: 0.38 (0.14) and 0.46 (0.11), respectively. These scores significantly decreased (improved) from baseline for patients receiving BOS versus placebo (grade: least squares mean change [SE]: placebo vs. BOS, -0.04 [0.03] vs. -0.24 [0.02]; P<0.0001; stage: -0.01 [0.02] vs. -0.19 [0.02]; P<0.0001). EoE HSS total scores improved for 6 of the 8 and 5 of the 8 histopathologic features for grade and stage, respectively, versus placebo. Change in EoE HSS total scores correlated moderately but significantly with change in endoscopic severity (endoscopic reference score; grade: R=0.5349; stage: R=0.5416; both P<0.0001). Change in EoE HSS stage total score correlated weakly with change in Dysphagia Symptom Questionnaire scores (grade: R=0.1925; P=0.0740; stage: R=0.2135; P=0.0471). These data demonstrate that the EoE HSS is a valuable endpoint of treatment response in randomized clinical trials and should be considered for future trials for EoE.
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Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Lan Lan
- Shire, a Takeda Company, Lexington, MA
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Kanwal F. Covering the Year in CGH: 2019. Clin Gastroenterol Hepatol 2020; 18:3-10. [PMID: 31706059 DOI: 10.1016/j.cgh.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gonsalves NP, Aceves SS. Diagnosis and treatment of eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145:1-7. [PMID: 31910983 PMCID: PMC6986782 DOI: 10.1016/j.jaci.2019.11.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is an eosinophil-rich, TH2 antigen-mediated disease of increasing pediatric and adult worldwide prevalence. Diagnosis requires greater than or equal to 15 eosinophils per high-power field on light microscopy. Symptoms reflect esophageal dysfunction, and typical endoscopic features include linear furrows, white plaques, and concentric rings. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. Therapies include proton pump inhibitors, elimination diets, and topical corticosteroids. Effective treatment can reverse tissue fibrosis in some patients, as well as decrease the rate of food impactions. Esophageal dilation might be required to increase luminal patency. The chronic nature of EoE necessitates long-term therapy to avoid disease recurrence and complications. This review serves the function of providing the current state-of-the-art diagnostic criteria and disease management for adult and pediatric EoE.
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Affiliation(s)
- Nirmala P Gonsalves
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Ill.
| | - Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, and Rady Children's Hospital, San Diego, Calif.
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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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Dellon ES, Gupta SK. A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:2149-2160. [PMID: 30710696 PMCID: PMC6667323 DOI: 10.1016/j.cgh.2019.01.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
While the diagnosis and initial treatment of eosinophilic esophagitis are becoming more standardized, there are still major gaps in knowledge related to measuring treatment response. One such question centers on how to measure treatment response and what treatment endpoints should be. This impacts not only patient care and engagement in decision-making, but also the field of drug development. In addition, studies so far have use a myriad of treatment endpoints including over a dozen histologic endpoint criteria. This review will discuss the various stakeholders involved in assessment of treatment endpoints of a complex condition, including patients, practitioners and regulatory agencies, and the care settings in which treatment response is assessed, including routine clinical care, clinical trials, and observational studies. Potential parameters or treatment endpoints such as histology, symptoms, patient-reported outcomes, endoscopy, and biomarkers are discussed along with associated challenges and opportunities. A framework on how to define treatment outcomes is discussed and a conceptual approach treatment response is proposed. This takes into account histology, symptoms, and endoscopic findings and harnesses existing, validated tools. It includes definitions of nonresponse, complete normalization, and a graded response category between these 2 extremes, and also permits flexibility and latitude for modifications as newer knowledge emerges. In addition, ways to position the pediatric population in these endeavors are discussed as are future research directions.
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Affiliation(s)
- 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; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, University of Illinois College of Medicine, Peoria, IL
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Schauer F, Monasterio C, Technau-Hafsi K, Kern JS, Lazaro A, Deibert P, Hasselblatt P, Schwacha H, Heeg S, Brass V, Küllmer A, Schmidt AR, Schmitt-Graeff A, Kreisel W. Esophageal lichen planus: towards diagnosis of an underdiagnosed disease. Scand J Gastroenterol 2019; 54:1189-1198. [PMID: 31608788 DOI: 10.1080/00365521.2019.1674375] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Although lichen planus (LP) is a common skin disorder, the prevalence of esophageal involvement (ELP) and its clinical manifestations are poorly defined. We aimed to establish diagnostic criteria and characterize disease outcomes of ELP.Methods: Clinical, endoscopic, histological, and immunofluorescence data from consecutive patients with known LP between 2013 and 2018 were analyzed. We established endoscopic (denudation and tearing of the mucosa, hyperkeratosis and trachealization) and histological criteria (mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis, dyskeratosis, and fibrinogen deposits along the basement membrane) to grade disease severity. Endoscopic findings were correlated with clinical symptoms. Response to medical therapy was monitored.Results: Fifty-two consecutive patients (median age 59.5 years) were analyzed. According to our grading system, 16 patients were considered as severe and 18 as mild ELP. Dysphagia was the only symptom which differentiated patients with severe (14/16) or mild ELP (8/18) from patients without ELP (1/18). Concomitant oral and genital involvement of LP was associated with the presence of ELP, while oral involvement alone was not. Follow-up of 14/16 patients with severe EPL for at least one year revealed that most of these patients responded to topical corticosteroids (budesonide: n = 9/10 or fluticasone n = 2/2). Three budesonide patients experienced a resolution of symptomatic esophageal stenosis.Conclusions: Esophageal involvement of LP is frequent, but may be asymptomatic. ELP can be diagnosed using the diagnostic criteria proposed here. Dysphagia and combined oral and genital manifestation are associated with ELP. Therapy with topical corticosteroids appears to be a prudent therapeutic approach for ELP.
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Affiliation(s)
- Franziska Schauer
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carmen Monasterio
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kristin Technau-Hafsi
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Steffen Kern
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Dermatology, Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - Adhara Lazaro
- Department of Medicine, Institute of Exercise and Occupational Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Deibert
- Department of Medicine, Institute of Exercise and Occupational Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Hasselblatt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Henning Schwacha
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Heeg
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker Brass
- Kliniken des Landkreises Lörrach GmbH, Gastroenterology, Germany
| | - Armin Küllmer
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Robert Schmidt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Annette Schmitt-Graeff
- Institute of Clinical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Wolfgang Kreisel
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Collins CA, Palmquist J, Proudfoot JA, Qian A, Wangberg H, Khosh-Hemmat E, Dohil R, Aceves SS. Evaluation of long-term course in children with eosinophilic esophagitis reveals distinct histologic patterns and clinical characteristics. J Allergy Clin Immunol 2019; 144:1050-1057.e5. [PMID: 31255641 PMCID: PMC6820855 DOI: 10.1016/j.jaci.2019.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic and increasingly prevalent antigen-driven disease. There is a paucity of information on long-term course in children. OBJECTIVE We sought to understand the longitudinal trajectory of pediatric EoE during routine clinical care. METHODS We prospectively enrolled children into an EoE database and reviewed their medical and pathologic records over 13 years. RESULTS From 2011 to 2015, 146 children with EoE seen for their first visit at our center had 2 or more years of follow-up and 3 or more endoscopies over an average follow-up period of 5.13 years (range, 2-13 years). Longitudinal eosinophilic inflammation during treatment demonstrated 3 patterns over time. Children with less than 15 eosinophils/high-power field (hpf) for greater than 75% of their follow-up period were termed continuous responders (CRs). Children with waxing and waning inflammation of less than 15 eosinophils/hpf for less than 75% but 25% or more of the follow-up period were termed intermittent responders (IRs). Nonresponders (NRs) were defined as having less than 15 eosinophils/hpf for less than 25% of their follow-up. Fifty-nine (40%) of 146 patients were CRs, 65 (45%) of 146 were IRs, and 22 (15%) of 146 were NRs. CRs differed from IRs and NRs on the parameter of male/female ratio (1:1 in CRs, 4:1 in IRs, and 6:1 in NRs; P < .001) and in their initial response to any therapy, including proton pump inhibitors (P < .001). Endoscopic severity correlated with esophageal eosinophilia (r = 0.73, P < .001). On multivariate analysis, female sex and initial therapeutic response to medications or elimination diet were associated with long-term control of esophageal eosinophilia. CONCLUSIONS Long-term pediatric EoE followed 3 different longitudinal trajectories of inflammation. The long-term histologic groups differed significantly in biological sex and initial therapeutic response.
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Affiliation(s)
- Cathleen A Collins
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Jacob Palmquist
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - James A Proudfoot
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Altman Clinical Translational Research Institute, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Alex Qian
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif
| | - Hannah Wangberg
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif
| | - Emad Khosh-Hemmat
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Ranjan Dohil
- Division of Gastroenterology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Seema S Aceves
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif.
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Intranasal Application of Budesonide Attenuates Lipopolysaccharide-Induced Acute Lung Injury by Suppressing Nucleotide-Binding Oligomerization Domain-Like Receptor Family, Pyrin Domain-Containing 3 Inflammasome Activation in Mice. J Immunol Res 2019; 2019:7264383. [PMID: 30937316 PMCID: PMC6415278 DOI: 10.1155/2019/7264383] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/20/2018] [Accepted: 11/14/2018] [Indexed: 12/26/2022] Open
Abstract
Aim To investigate the protective effects of budesonide against lipopolysaccharide- (LPS-) induced acute lung injury (ALI) in a murine model and its underlying mechanism. Methods Adult male C57BL/6 mice were divided into three groups: control, ALI, and ALI + budesonide groups. LPS (5 mg/kg) was intratracheally injected to induce ALI in mice. Budesonide (0.5 mg/kg) was intranasally given 1 h before LPS administration in the ALI + budesonide group. Twelve hours after LPS administration, all mice were sacrificed. Hematoxylin-eosin staining and pathological scores were used to evaluate pathological injury. Bronchoalveolar lavage was performed. The numbers of total cells, neutrophils, and macrophages in the bronchoalveolar lavage fluid (BALF) were counted. Enzyme-linked immunosorbent assay was employed to detect the proinflammatory cytokines in BALF and serum, including tumor necrosis factor- (TNF-) α, monocyte chemoattractant protein- (MCP-) 1, and interleukin- (IL-) 1β. The expression of the nucleotide-binding oligomerization domain-like receptor family, pyrin domain-containing 3 (NLRP3) inflammasome was detected by western blotting. A lethal dose of LPS (40 mg/kg, intraperitoneally) was injected to evaluate the effects of budesonide on survival rates. Results Budesonide pretreatment dramatically attenuated pathological injury and reduced pathological scores in mice with ALI. Budesonide pretreatment obviously reduced the numbers of total cells, neutrophils, and macrophages in the BALF of mice with ALI. Additionally, budesonide dramatically reduced TNF-α and MCP-1 expression in the BALF and serum of mice with ALI. Budesonide significantly suppressed NLRP3 and pro-caspase-1 expression in the lung and reduced IL-1β content in the BALF, indicating that budesonide inhibited the activation of the NLRP3 inflammasome. Furthermore, we found that budesonide improved the survival rates of mice with ALI receiving a lethal dose of LPS. Conclusion Suppression of NLRP3 inflammasome activation in mice via budesonide attenuated lung injury induced by LPS in mice with ALI.
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