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Chehade M, Jensen ET, Wright BL. Addressing health disparities and transitions of care in eosinophilic gastrointestinal diseases. J Allergy Clin Immunol 2024; 153:1526-1528. [PMID: 38593869 DOI: 10.1016/j.jaci.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/18/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Departments of Pediatrics and Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Elizabeth T Jensen
- Departments of Epidemiology and Prevention and Internal Medicine, Gastroenterology Section, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz; Division of Allergy and Immunology, Phoenix Children's Hospital, Phoenix, Ariz
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Navarro P, Feo-Ortega S, Casabona-Francés S, Gutiérrez-Junquera C, Savarino EV, Amorena E, Fernández-Fernández S, Pérez-Martínez I, Oliva S, Barrio J, Masiques-Mas ML, Guardiola-Arévalo A, Guagnozzi D, Racca F, Betoré E, Votto M, Rodríguez-Sánchez A, Barrio ML, Blas-Jhon L, Sánchez-Vegazo CT, García-Morales N, Krarup AL, Dainese R, Martín-Dominguez V, García-Díaz A, Maniero D, Santander C, Arias Á, Laserna-Mendieta EJ, Lucendo AJ. Determinant factors for first-line treatment choice and effectiveness in pediatric eosinophilic esophagitis: an analysis of the EUREOS EoE CONNECT registry. Eur J Pediatr 2024:10.1007/s00431-024-05618-z. [PMID: 38819501 DOI: 10.1007/s00431-024-05618-z] [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: 03/09/2024] [Revised: 05/03/2024] [Accepted: 05/17/2024] [Indexed: 06/01/2024]
Abstract
This study compared short-term effectiveness of proton pump inhibitors (PPI), swallowed topical corticosteroids (STC), and dietary therapies in reversing clinical and histological features in pediatric patients with eosinophilic esophagitits (EoE). Determinants for treatment choice and PPI therapy effectiveness were also assessed. A cross-sectional study analysis of patients under 18 years old recruited onto the multicenter EoE CONNECT registry was performed. Clinico-histological response was defined as symptomatic improvement plus a peak eosinophil count below 15 per high-power field after treatment. Effectiveness of first-line options used in monotherapy was compared. Overall, 393 patients (64% adolescents) receiving PPI, STC, or dietary monotherapy to induce EoE remission were identified. PPI was the preferred option (71.5%), despite STC providing the highest clinico-histological response rates (66%) compared to PPI (44%) and diet (42%). Logistic regression identified fibrotic features and recruitment at Italian sites independently associated to first-line STC treatment; age under 12 associated to dietary therapy over other options. Analysis of 262 patients in whom PPI effectiveness was evaluated after median (IQR) 96 (70-145) days showed that this effectiveness was significantly associated with management at pediatric facilities and use of high PPI doses. Among PPI responders, decrease in rings and structures in endoscopy from baseline was documented, with EREFS fibrotic subscore for rings also decreasing among responders (0.27 ± 0.63 vs. 0.05 ± 0.22, p < 0.001). Conclusion: Initial therapy choice for EoE depends on endoscopic phenotype, patient's age, and patients' origin. High PPI doses and treatment in pediatric facilities significantly determined effectiveness, and reversed fibrotic endoscopic features among responders. What is Known: • Proton pump inhibitors are widely used to induce and maintain remission in EoE in real practice, despite other first-line alternative therapies possibly providing higher effectiveness. What is New: • Proton pump inhibitors represent up to two-thirds of first-line monotherapies used to induce EoE remission in pediatric and adolescent patients with EoE. The choice of STC as first-line treatment for EoE was significantly associated with fibrotic features at baseline endoscopy and recruitment in Italian centers; age less than 12 years was associated with dietary therapy. • PPI effectiveness was found to be determined by use of high doses, attendance at pediatric facilities, presenting inflammatory instead of fibrotic or mixed phenotypes, and younger age. Among responders, PPI therapy reversed both inflammatory and fibrotic features of EoE after short-term treatment.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Sara Feo-Ortega
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain
| | - Sergio Casabona-Francés
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienza Ospedaliera di Padova, Padua, Italy
| | - Edurne Amorena
- Department of Gastroenterology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
- Diet, Microbiota and Health Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza-University of Rome, Rome, Italy
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | | | - Danila Guagnozzi
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia; and Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | | | | | | | - Anne Lund Krarup
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Raffaella Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les Pins, Antibes, France
| | - Verónica Martín-Dominguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Alejandro García-Díaz
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Research Unit, Hospital General Mancha-Centro, Alcázar de San Juan, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain.
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain.
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Ugalde-Triviño L, Molina-Jiménez F, H-Vázquez J, Relaño-Rupérez C, Arias-González L, Casabona S, Pérez-Fernández MT, Martín-Domínguez V, Fernández-Pacheco J, Lucendo AJ, Bernardo D, Santander C, Majano P. Circulating immunome fingerprint in eosinophilic esophagitis is associated with clinical response to proton pump inhibitor treatment. Front Immunol 2024; 15:1374611. [PMID: 38646544 PMCID: PMC11026586 DOI: 10.3389/fimmu.2024.1374611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives The aim of the study was to characterize the circulating immunome of patients with EoE before and after proton pump inhibitor (PPI) treatment in order to identify potential non-invasive biomarkers of treatment response. Methods PBMCs from 19 healthy controls and 24 EoE patients were studied using a 39-plex spectral cytometry panel. The plasmacytoid dendritic cell (pDC) population was differentially characterized by spectral cytometry analysis and immunofluorescence assays in esophageal biopsies from 7 healthy controls and 13 EoE patients. Results Interestingly, EoE patients at baseline had lower levels of circulating pDC compared with controls. Before treatment, patients with EoE who responded to PPI therapy had higher levels of circulating pDC and classical monocytes, compared with non-responders. Moreover, following PPI therapy pDC levels were increased in all EoE patients, while normal levels were only restored in PPI-responding patients. Finally, circulating pDC levels inversely correlated with peak eosinophil count and pDC count in esophageal biopsies. The number of tissue pDCs significantly increased during active EoE, being even higher in non-responder patients when compared to responder patients pre-PPI. pDC levels decreased after PPI intake, being further restored almost to control levels in responder patients post-PPI. Conclusions We hereby describe a unique immune fingerprint of EoE patients at diagnosis. Moreover, circulating pDC may be also used as a novel non-invasive biomarker to predict subsequent response to PPI treatment.
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Affiliation(s)
- Lola Ugalde-Triviño
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Francisca Molina-Jiménez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Juan H-Vázquez
- Mucosal Immunology Lab, Unit of Excellence Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and CSIC, Valladolid, Spain
| | - Carlos Relaño-Rupérez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Bioinformatics Unit, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Laura Arias-González
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sergio Casabona
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - María Teresa Pérez-Fernández
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Verónica Martín-Domínguez
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Jennifer Fernández-Pacheco
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - David Bernardo
- Mucosal Immunology Lab, Unit of Excellence Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and CSIC, Valladolid, Spain
- Centro de Investigaciones Biomedicas en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Cecilio Santander
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Pedro Majano
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Cellular Biology, Faculty of Biology, Universidad Complutense de Madrid, Madrid, Spain
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Rodríguez-Alcolado L, Navarro P, Arias-González L, Grueso-Navarro E, Lucendo AJ, Laserna-Mendieta EJ. Proton-Pump Inhibitors in Eosinophilic Esophagitis: A Review Focused on the Role of Pharmacogenetics. Pharmaceutics 2024; 16:487. [PMID: 38675148 PMCID: PMC11054109 DOI: 10.3390/pharmaceutics16040487] [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: 02/23/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Proton-pump inhibitors (PPIs) are the most administered first-line treatment for eosinophilic esophagitis (EoE). However, only around half of EoE patients respond histologically to a double dosage of PPI. In addition, 70% of responders maintain EoE in remission after tapering the PPI dose. In order to avoid endoscopy with biopsies-the only accurate method of assessing PPI response-efforts have been made to identify PPI responder patients. The clinical or endoscopic features and biomarkers evaluated so far, however, have not proven to be sufficient in predicting PPI response. Although new approaches based on omics technologies have uncovered promising biomarkers, the specialized and complex procedures required are difficult to implement in clinical settings. Alternatively, PPI pharmacogenetics based on identifying variations in CYP2C19 and STAT6 genes have shown promising results in EoE, and could easily be performed in most laboratories. Other genetic variations have also been associated with PPI response and may explain those cases not related to CYP2C19 or STAT6. Here, we provide an overview of PPI treatment in EoE and evidence of how genetic variations in CYP2C19 and other genes could affect PPI effectiveness, and also discuss studies evaluating the role of pharmacogenetics in predicting PPI response in patients with EoE.
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Affiliation(s)
- Leticia Rodríguez-Alcolado
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Department of Surgery, Medical and Social Sciences, Universidad de Alcalá, 28805 Alcalá de Henares, Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Elena Grueso-Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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Sorge A, Coletta M, Elli L, Bredenoord AJ. Clinical practices and adherence to guidelines for eosinophilic esophagitis: A European survey. Dig Liver Dis 2024:S1590-8658(23)01118-0. [PMID: 38290961 DOI: 10.1016/j.dld.2023.12.011] [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: 09/11/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND We aimed to assess the clinical practices and adherence to guidelines for adult Eosinophilic Esophagitis (EoE) patients in Europe. METHODS A cross-sectional web survey containing 23 questions was distributed to members of the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract (EUREOS) and the Italian Association of Hospital Gastroenterologists and digestive endoscopists (AIGO). We conducted a subgroup analysis to assess the impact of EoE expertise and practice setting on clinical practices. RESULTS 228 physicians from 18 European countries participated. Adherence to guidelines varied from 72% to 98.6%. 83.4% of total respondents obtained ≥ 6 esophageal biopsies in suspected EoE. 42% of total respondents, 82.5% of EoE experts (vs. non-experts 33%; P < 0.0001), and 55% of academics (vs. 29.1 non-academics; P < 0.0001) routinely used the EREFS score. Regarding first-line therapy, 82.9% of total respondents prescribed proton pump inhibitors, 41.6% topical steroids, 20.6% elimination diets, and 9.2% combination therapies. Only 72% of respondents used symptoms and endoscopy with <15 Eosinophils/HPF to define treatment response. 21.5% of all respondents did not prescribe maintenance therapies and 12.7% discontinued therapy before response evaluation endoscopy. CONCLUSION Our findings revealed significant heterogeneity in practice patterns and suboptimal adherence to EoE guidelines across Europe. Expertise in EoE and working in an academic hospital positively influenced clinical practices and adherence to guidelines.
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Affiliation(s)
- Andrea Sorge
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Marina Coletta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Schreiner P, Greuter T. To Scope or Not to Scope, That is the Question. Clin Gastroenterol Hepatol 2024; 22:203-204. [PMID: 37061108 DOI: 10.1016/j.cgh.2023.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Philipp Schreiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Greuter
- Department of Internal Medicine, GZO - Zurich Regional Health Center, Wetzikon, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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7
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Benitez AJ, McGar A, Kohser K, Gibbons T, Muir A, Mascarenhas M, Rossi C, Dogias F, Golden A, Kassam-Adams N, Marsac ML. The Cellie Coping Kit for children with Eosinophilic Esophagitis: Feasibility, acceptability, and preliminary outcomes. J Child Health Care 2023; 27:374-385. [PMID: 34978212 PMCID: PMC11007661 DOI: 10.1177/13674935211064126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Children with eosinophilic esophagitis (EoE) are faced with ongoing treatments that can impact their wellbeing. There are no evidence-based resources that families can implement independently to cope with EoE-related stressors. This study aimed to examine acceptability, feasibility, and preliminary outcomes of the newly developed Cellie Coping Kit for Children with EoE intervention. Forty child-caregiver dyads completed a baseline assessment (T1) and initiated the intervention; 30 (75%) child participants and 33 (82.5%) caregivers were retained to follow-up (T2). Of those who completed the T2 assessment, most reported that the intervention was easy to use (>90%) and would recommend the intervention to others (>90%). The intervention was feasible: >70% used the kit, and most indicated they would use it again (>75%). More than half of families reported learning new information and/or coping strategies. No statistically significant changes were identified in comparing T1 and T2 coping and health-related quality of life. These findings suggest that the Cellie Coping Kit for Children with EoE is a promising intervention in that it was well accepted, feasible, and helped many families learn novel strategies on how to manage EoE challenges. Future research should examine how to strengthen the intervention to achieve longer-term targeted outcomes.
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Affiliation(s)
- Alain J Benitez
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley McGar
- University of Kentucky School of Medicine and Kentucky Children’s Hospital, Lexington, KY, USA
| | - Kristen Kohser
- Center for Pediatric Traumatic Stress, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Troy Gibbons
- University of Kentucky School of Medicine and Kentucky Children’s Hospital, Lexington, KY, USA
| | - Amanda Muir
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen Rossi
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Francesca Dogias
- Center for Pediatric Traumatic Stress, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anneliese Golden
- Center for Pediatric Traumatic Stress, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nancy Kassam-Adams
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Traumatic Stress, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meghan L Marsac
- University of Kentucky School of Medicine and Kentucky Children’s Hospital, Lexington, KY, USA
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Schreiner P, Balcar L, Schlager H, Madl C, Ziachehabi A, Mader M, Steidl K, Dinkhauser P, Reider S, Dolak W, Dejaco C, Gröchenig HP, Novacek G. Management of suspected and known eosinophilic esophagitis-a nationwide survey in Austria. Wien Klin Wochenschr 2023; 135:406-413. [PMID: 37071203 PMCID: PMC10444684 DOI: 10.1007/s00508-023-02198-0] [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] [Received: 01/28/2023] [Accepted: 03/19/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus with increasing incidence and dysphagia as the main symptom. The management of suspected or known EoE by Austrian endoscopists has not been investigated yet. METHODS A web-based survey with 13 questions about the management of EoE was sent to endoscopists via the Austrian Society of Gastroenterology and Hepatology (ÖGGH). RESULTS A total of 222 endoscopists (74% gastroenterologists, 23% surgeons, and 2% pediatricians; 68% working in a hospital) from all 9 states participated. In patients with dysphagia but a normal appearing esophagus, 85% of respondents reported always taking biopsies; however, surgeons were less likely to obtain biopsies compared to gastroenterologists ("always" 69% vs. 90%, "sometimes" 29% vs. 10%, "never" 2% vs. 0%, p < 0.001). The approved budesonide orodispersible tablet is the preferred first-line drug used in EoE, ahead of proton pump inhibitors (PPI). Only 65% of participants monitor the patients by endoscopy and histology after 12 weeks of induction therapy, 26% do not continue maintenance therapy, and 22% monitor patients only when symptomatic. CONCLUSION The vast majority of Austrian endoscopists adhere to the European and US guidelines in cases of suspected EoE. In contrast, despite the chronic disease course, a significant percentage of providers indicate not to use maintenance therapy and monitor the patients routinely.
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Affiliation(s)
- Philipp Schreiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hansjörg Schlager
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, University Hospital Graz, Graz, Austria
| | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | | | - Markus Mader
- Department of Internal Medicine II, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Karin Steidl
- Department of Internal Medicine, Hospital Brothers of Mercy, St. Veit an der Glan, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Division of Gastroenterology and Hepatology, Endocrinology and Rheumatology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Simon Reider
- Department of Internal Medicine 2 (Gastroenterology and Hepatology), Faculty of Medicine, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Clemens Dejaco
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hans Peter Gröchenig
- Department of Internal Medicine, Hospital Brothers of Mercy, St. Veit an der Glan, Austria
| | - Gottfried Novacek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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9
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Murray FR, Kreienbühl A, Straumann A, Biedermann L, Schreiner P. Natural History of Patients Lost to Follow-up After Esophageal Food Impaction. Clin Gastroenterol Hepatol 2023; 21:2413-2414. [PMID: 35868442 DOI: 10.1016/j.cgh.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland; Department of Gastroenterology & Hepatology, Stadtspital Triemli Zurich, Zurich, Switzerland
| | - Andrea Kreienbühl
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland.
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10
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Day K, Bredenoord AJ, Skypala I, Spergel J, Bickford K, Noble A, Nunn AM. Addressing educational gaps through multidisciplinary team education in eosinophilic oesophagitis management. JOURNAL OF CME 2023; 12:2230033. [PMID: 37426427 PMCID: PMC10327516 DOI: 10.1080/28338073.2023.2230033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
Once considered a rare disease, eosinophilic oesophagitis (EoE) is becoming increasingly prevalent, yet many healthcare professionals (HCPs) remain unfamiliar with the underlying pathophysiology and optimal management approaches. For this study, we developed a faculty-led, online, continuing medical education activity on EoE. The effectiveness of this activity was evaluated according to Moore's framework, with changes in knowledge and competence (Moore's Levels 3 and 4) assessed for a cohort of gastroenterologists, dietitians, allergists and immunologists (N = 300), using questionnaires completed before and after participation. Changes in HCP confidence in treating EoE were also reported and remaining educational gaps were identified. The activity was viewed by a global audience of 5,330 participants within 6 months, and significant improvements in knowledge and competence were reported following participation in the activity across all specialities, regions and experience (mean [standard deviation] score pre- versus post-activity: 4.32 [1.38] versus 5.46 [0.82]; p < 0.001). Confidence in treating EoE also increased from pre- to post-activity, with the proportion of participants reporting that they felt moderately or extremely confident increasing from 53% to 82%. Several educational unmet needs were identified, which can be used to inform the design of future educational activities in EoE.
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Affiliation(s)
- Kathy Day
- Medical and Editorial, touchIME Ltd, Stockport, UK
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Isabel Skypala
- Department of Allergy and Clinical Immunology, Royal Brompton & Harefield Hospitals, Part of Guys & St Thomas NHS Foundation Trust, London, UK
| | - Jonathan Spergel
- Allergy Section, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Anne M Nunn
- Medical and Editorial, touchIME Ltd, Stockport, UK
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11
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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: 4] [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: 01/18/2023] [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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12
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Laserna-Mendieta EJ, Navarro P, Casabona-Francés S, Savarino EV, Pérez-Martínez I, Guagnozzi D, Barrio J, Perello A, Guardiola-Arévalo A, Betoré-Glaria ME, Blas-Jhon L, Racca F, Krarup AL, Gutiérrez-Junquera C, Fernández-Fernández S, la Riva SD, Naves JE, Carrión S, García-Morales N, Roales V, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Feo-Ortega S, Ghisa M, Maniero D, Suarez A, Llerena-Castro R, Gil-Simón P, de la Peña-Negro L, Granja-Navacerrada A, Alcedo J, Hurtado de Mendoza-Guena L, Pellegatta G, Pérez-Fernández MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Differences between childhood- and adulthood-onset eosinophilic esophagitis: An analysis from the EoE connect registry. Dig Liver Dis 2023; 55:350-359. [PMID: 36280437 DOI: 10.1016/j.dld.2022.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 09/19/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Direct comparisons of childhood- and adulthood-onset eosinophilic esophagitis (EoE) are scarce. AIM To compare disease characteristics, endoscopic and histological features, allergic concomitances and therapeutic choices across ages. METHODS Cross-sectional analysis of the EoE CONNECT registry. RESULTS The adulthood-onset cohort (those diagnosed at ≥18y) comprised 1044 patients and the childhood-onset cohort (patients diagnosed at <18 y), 254. Vomiting, nausea, chest and abdominal pain, weight loss, slow eating and food aversion were significantly more frequent in children; dysphagia, food bolus impaction and heartburn predominated in adults. A family history of EoE was present in 16% of pediatric and 8.2% of adult patients (p<0.001). Concomitant atopic diseases did not vary across ages. Median±IQR diagnostic delay (years) from symptom onset was higher in adults (2.7 ± 6.1) than in children (1 ± 2.1; p<0.001). Esophageal strictures and rings predominated in adults (p<0.001), who underwent esophageal dilation more commonly (p = 0.011). Inflammatory EoE phenotypes were more common in children (p = 0.001), who also presented higher eosinophil counts in biopsies (p = 0.015) and EREFS scores (p = 0.017). Despite PPI predominating as initial therapy in all cohorts, dietary therapy and swallowed topical corticosteroids were more frequently prescribed in children (p<0.001). CONCLUSIONS Childhood-onset EoE has differential characteristics compared with adulthood-onset, but similar response to treatment.
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Affiliation(s)
- Emilio José Laserna-Mendieta
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Pilar Navarro
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Sergio Casabona-Francés
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain; Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology. Hospital Universitario Vall d'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Jesús Barrio
- Servicio de Gastroenterología. Hospital Universitario Río Hortega. Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Antonia Perello
- Department of Gastroenterology. Hospital de Viladecans, Viladecans, Spain; Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Antonio Guardiola-Arévalo
- Department of Gastroenterology. Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | | | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Francesca Racca
- Personalized Medicine Asthma and Allergy Clinic. Humanitas Clinical and Research Center (IRCCSS), Rozzano, Italy
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Naves
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | | | - Valentín Roales
- Department of Gastroenterology, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology. Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaella Dainese
- Department of Allergy. Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | - Sara Feo-Ortega
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Adolfo Suarez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain; Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology. Hospital Universitario Vall d'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paula Gil-Simón
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Servicio de Gastroenterología. Hospital Universitario Río Hortega. Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | | | | | - Javier Alcedo
- Department of Gastroenterology. Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Gaia Pellegatta
- Endoscopy Unit. Humanitas Clinical and Research Center (IRCCSS), Rozzano, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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Aceves SS, Dellon ES, Greenhawt M, Hirano I, Liacouras CA, Spergel JM. Clinical guidance for the use of dupilumab in eosinophilic esophagitis: A yardstick. Ann Allergy Asthma Immunol 2023; 130:371-378. [PMID: 36521784 DOI: 10.1016/j.anai.2022.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
The Joint Task Force for the American Academy of Allergy Asthma Immunology and American College of Allergy Asthma Immunology and the American Gastroenterology Association recently published guidelines for the management of eosinophilic esophagitis (EoE). Because the guideline was published, dupilumab became the first and only medication to gain regulatory approval for the treatment of EoE. This expert opinion document provides a framework for how the clinician can consider using dupilumab in the treatment strategy for patients with EoE.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California and Rady Children's Hospital, San Diego, California
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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14
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Chang JW, Kliewer K, Katzka DA, Peterson KA, Gonsalves N, Gupta SK, Furuta GT, Dellon ES. Provider Beliefs, Practices, and Perceived Barriers to Dietary Elimination Therapy in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:2071-2074. [PMID: 36066475 PMCID: PMC9722505 DOI: 10.14309/ajg.0000000000001988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/15/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Despite effective dietary treatments, physicians prefer medications for eosinophilic esophagitis (EoE). METHODS We conducted a web-based survey of providers to assess the perceived effectiveness, practice patterns, and barriers to EoE dietary therapy. RESULTS Providers view diet as the least effective treatment. The greatest barrier was the belief that patients are disinterested and unlikely to adhere (58%). With less access to dietitians (56%), nonacademic providers often manage diets without dietitian guidance (41%). DISCUSSION Given high patient acceptance for diets and multiple treatment options for EoE, clinicians need evidence-based knowledge on EoE diets, access to dietitians, and awareness of patient preferences.
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Affiliation(s)
- Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children and Community Health Network, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - 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, USA
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15
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Schreiner P, Safroneeva E, Schoepfer A, Greuter T, Biedermann L, Schlag C, Labenz J, Auth MKH, Bredenoord AJ, Chang JW, Bonis PA, Rothenberg ME, Collins MH, Hirano I, Gupta SK, Katzka DA, Dellon ES, Straumann A, Furuta GT, Gonsalves N. Management of eosinophilic esophagitis associated food impaction in Europe and the United States. Dis Esophagus 2022; 35:6516224. [PMID: 35088073 DOI: 10.1093/dote/doac003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is the most common cause of esophageal food impaction (EFI). Approaches to management of EFI due to EoE have not been well characterized. We conducted a web-based survey to understand approaches to management of EFI due to EoE among endoscopists. Questions focused on management of patients from presentation to post-endoscopy follow-up. The survey was administered to a list of eligible candidates provided by societies of gastroenterology. A total of 308 endoscopists completed the questionnaire. The majority (83%) practiced in Europe and treated adults (78%). Most agreed patients should be advised to seek emergency care (66%) within 1 to 2 hours (41% agreement). There was agreement that medications to induce vomiting should be avoided (84%) and that blood tests or imaging studies were usually not required before endoscopy. By contrast, there was more variability in the type of sedation recommended and the need for endotracheal intubation, especially when comparing more experienced with less experienced EoE-endoscopists. Overall, fewer than half (43%) respondents recommended obtaining esophageal biopsies during the initial endoscopy. However, there were significant differences in the proportion who recommended biopsies based on level of EoE-experience (25, 52, 77%, P < 0.001; less vs. moderate vs. very experienced) and comparing pediatric and adult endoscopists (32, vs. 79%, P < 0.001; adult vs. pediatric). There exists heterogeneity among endoscopists in recommendations to manage EFI in patients with EoE. These findings support development of clinical guidelines and new studies to clarify the rationale for best practices. Key summary: Established knowledge-The optimal management of patients with esophageal food impaction due to eosinophilic esophagitis from presentation at the emergency department to postendoscopy care is unclear. New findings-Considerable recommendation variation exists in the management of EFI in patients with EoE. Our findings provide a rationale for the creation of consensus practice guidelines and further study into best practices.
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Affiliation(s)
- Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Schlag
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung- Stilling, Siegen, Germany
| | - Marcus K H Auth
- Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, MA, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University/Community Health Network, Indianapolis, IN, USA
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
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Disease Burden and Unmet Need in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:1231-1241. [PMID: 35417421 DOI: 10.14309/ajg.0000000000001777] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/04/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease of increasing prevalence, characterized by symptoms of dysphagia and reduced quality of life. A dysregulated type 2 immune response to food and aeroallergen leads to barrier dysfunction, chronic esophageal inflammation, remodeling, and fibrosis. Patients with EoE have impaired quality of life because of dysphagia and other symptoms. They may also suffer social and psychological implications of food-related illness and expensive out-of-pocket costs associated with treatment. Disease burden in EoE is often compounded by the presence of comorbid type 2 inflammatory diseases. Current conventional treatments include elimination diet, proton pump inhibitors, and swallowed topical corticosteroids, as well as esophageal dilation in patients who have developed strictures. These treatments demonstrate variable response rates and may not always provide long-term disease control. There is an unmet need for long-term histologic, endoscopic, and symptomatic disease control; for targeted therapies that can normalize the immune response to triggers, reduce chronic inflammation, and limit or prevent remodeling and fibrosis; and for earlier diagnosis, defined treatment outcomes, and a greater understanding of patient perspectives on treatment. In addition, healthcare professionals need a better understanding of the patient perspective on disease burden, the disconnect between symptoms and disease activity, and the progressive nature of EoE and the need for continuous monitoring and maintenance treatment. In this review, we explore the progression of disease over the patient's lifespan, highlight the patient perspective on disease, and discuss the unmet need for effective long-term treatments.
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17
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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: 25] [Impact Index Per Article: 12.5] [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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18
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology 2022; 163:59-76. [PMID: 35606197 PMCID: PMC9233087 DOI: 10.1053/j.gastro.2022.03.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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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.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Bob Geng
- University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven, Connecticut; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden, Connecticut
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children, Indianapolis, Indiana; Community Health Network, Indianapolis, Indiana
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy, Immunology, University of California-San Diego, San Diego, California
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. J Allergy Clin Immunol 2022; 150:33-47. [PMID: 35606166 PMCID: PMC9549868 DOI: 10.1016/j.jaci.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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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.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora; Children's Hospital Colorado, Aurora
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati; Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora; Digestive Health Institute, Children's Hospital Colorado, Aurora
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam
| | - Bob Geng
- University of California San Diego, San Diego; Rady Children's Hospital, San Diego
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock; Arkansas Children's Hospital, Little Rock
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis; Riley Hospital for Children, Indianapolis; Community Health Network, Indianapolis
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid; Instituto de Investigación Sanitaria La Princesa, Madrid
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville
| | | | | | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora
| | - Seema S Aceves
- Rady Children's Hospital, San Diego; Division of Allergy, Immunology, University of California-San Diego, San Diego
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Navarro P, Laserna-Mendieta EJ, Casabona S, Savarino E, Pérez-Fernández MT, Ghisa M, Pérez-Martínez I, Guagnozzi D, Perelló A, Guardiola-Arévalo A, Racca F, Betoré E, Blas-Jhon L, Krarup AL, Martín-Domínguez V, Maniero D, Suárez A, Llerena-Castro R, de la Peña-Negro L, Navacerrada AG, Pellegatta G, Alcedo J, de Hurtado Mendoza-Guena L, Feo-Ortega S, Barrio J, Gutiérrez-Junquera C, Fernández-Fernández S, De la Riva S, E Navés J, Carrión S, Ciriza de Los Ríos C, García-Morales N, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Palomeque MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J 2022; 10:507-517. [PMID: 35578565 PMCID: PMC9189464 DOI: 10.1002/ueg2.12240] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. Objective To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Methods Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Results Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). Conclusion The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Viladecans, Spain
| | | | - Francesca Racca
- Personalized Medicine, Asthma and Allergy. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Adolfo Suárez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Gaia Pellegatta
- Endoscopy Unit. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Javier Alcedo
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Sara Feo-Ortega
- Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Navés
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | - Constanza Ciriza de Los Ríos
- Department of Gastroenterology. Hospital Clínico Universitario San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Madrid, Spain.,Universidad Complutense, Madrid, Spain
| | | | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaela Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | | | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Lucendo AJ, Santander C, Savarino E, Guagnozzi D, Pérez-Martínez I, Perelló A, Guardiola-Arévalo A, Barrio J, Elena Betoré-Glaria M, Gutiérrez-Junquera C, Ciriza de los Ríos C, Racca F, Fernández-Fernández S, Blas-Jhon L, Lund Krarup A, de la Riva S, Naves JE, Carrión S, Rodríguez Oballe JA, García-Morales N, Tamarit-Sebastián S, Navarro P, Arias Á, Laserna-Mendieta EJ, Casabona-Francés S, Pérez-Fernández T, Llerena Castro R, Ghisa M, Manie D, Pellegatta G, Suárez A, Alcedo J, Gil Simón P, Teresa Palomeque M, Asensio T, Granja-Navacerrada A, de Mendoza Guena LH, Rodríguez Sánchez A, Masiques Mas L, Dainese R, Feo-Ortega S. EoE CONNECT, the European Registry of Clinical, Environmental, and Genetic Determinants in Eosinophilic Esophagitis: rationale, design, and study protocol of a large-scale epidemiological study in Europe. Therap Adv Gastroenterol 2022; 15:17562848221074204. [PMID: 35126668 PMCID: PMC8814964 DOI: 10.1177/17562848221074204] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/27/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The growing prevalence of eosinophilic esophagitis (EoE) represents a considerable burden to patients and health care systems. Optimizing cost-effective management and identifying mechanisms for disease onset and progression are required. However, the paucity of large patient cohorts and heterogeneity of practice hinder the defining of optimal management of EoE. METHODS EoE CONNECT is an ongoing, prospective registry study initiated in 2016 and currently managed by EUREOS, the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract. Patients are managed and treated by their responsible specialists independently. Data recorded using a web-based system include demographic and clinical variables; patient allergies; environmental, intrapartum, and early life exposures; and family background. Symptoms are structurally assessed at every visit; endoscopic features and histological findings are recorded for each examination. Prospective treatment data are registered sequentially, with new sequences created each time a different treatment (active principle, formulation, or dose) is administered to a patient. EoE CONNECT database is actively monitored to ensure the highest data accuracy and the highest scientific and ethical standards. RESULTS EoE CONNECT is currently being conducted at 39 centers in Europe and enrolls patients of all ages with EoE. In its aim to increase knowledge, to date EoE CONNECT has provided evidence on the effectiveness of first- and second-line therapies for EoE in clinical practice, the ability of proton pump inhibitors to induce disease remission, and factors associated with improved response. Drug effects to reverse fibrous remodeling and endoscopic features of fibrosis in EoE have also been assessed. CONCLUSION This prospective registry study will provide important information on the epidemiological and clinical aspects of EoE and evidence as to the real-world and long-term effectiveness and safety of therapy. These data will potentially be a vital benchmark for planning future EoE health care services in Europe.
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Affiliation(s)
| | - Cecilio Santander
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain,Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d’Hebron, Barcelona, Spain,Digestive System Research Unit, Unitat de Fisiología I Fisiopatología Digestiva, Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Barcelona, Spain
| | - Antonio Guardiola-Arévalo
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria La Paz (IdiPAZ), Madrid, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constanza Ciriza de los Ríos
- Department of Gastroenterology, Hospital Clínico San Carlos, Universidad Complutense, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Sonia Fernández-Fernández
- Pediatric Gastroenterology, Hepatology and Nutrition, University Hospital Severo Ochoa, Leganés, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Acute Medicine and Trauma Care, Aalborg University Hospital, Aalborg, Denmark,Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Susana de la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E. Naves
- Gastroenterology Unit, Hospital Universitari Germans Trias i Pujol, CIBERehd, Badalona, Spain
| | - Silvia Carrión
- Gastrointestinal Motility Laboratory, Department of Surgery, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Juan Armando Rodríguez Oballe
- Department of Gastroenterology, University Hospital Santa María and University Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain,Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Clinical Laboratory, Hospital Universitario de La Princesa, Madrid, Spain
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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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23
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Chang JW, Chen VL, Rubenstein JH, Dellon ES, Wallner LP, De Vries R. What patients with eosinophilic esophagitis may not share with their providers: a qualitative assessment of online health communities. Dis Esophagus 2021; 35:6414418. [PMID: 34718475 PMCID: PMC9393058 DOI: 10.1093/dote/doab073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/09/2021] [Accepted: 09/18/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about how patients with eosinophilic esophagitis (EoE) experience their symptoms, receive care, and cope with their disease. Patients commonly seek peer support from online communities, which provide insights on unmet needs and barriers to care. We performed a qualitative analysis of electronic health forums to characterize patient-to-patient conversations about EoE symptoms and the experience of disease. METHODS We identified three publicly accessible electronic health forums hosting EoE communities. Conversation threads posted between July 2018 and June 2020 were coded using emergent and a priori codes based on the THRIVE conceptual framework of coping with chronic illness. RESULTS Of 659 threads (4,933 posts) collected over two years, a random sample of 240 threads (30 per 3-month quarter) were selected for analysis. Thematic saturation was reached after 172 threads. Patient experience of EoE was driven by their perspectives in four key domains: (i) perception of EoE as episodic rather than chronic, (ii) treatment choices, (iii) personal definitions of success in the disease, and (iv) views of providers. CONCLUSION Online health communities are a valuable and unfiltered source of patient perspectives that can be used to understand patient needs and goals. EoE patients interpret their disease as sporadic events and lack reliable sources of knowledge, which may influence how patients prioritize treatment. If providers are to succeed in providing high-quality EoE care, they need to equip themselves with evidence-based knowledge, engage in shared decision making, and look outside of clinical settings to recognize barriers to disease management.
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Affiliation(s)
- Joy W Chang
- Address correspondence to: Joy W. Chang, Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Vincent L Chen
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA,Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Evan S Dellon
- Division of Gastroenterology, Center for Esophageal and Swallowing Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Lauren P Wallner
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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The Effects of Patient Demographics on Outpatient Endoscopy Utilization in Children With Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2021; 73:537-541. [PMID: 33938526 DOI: 10.1097/mpg.0000000000003162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus that requires esophagogastroduodenoscopy (EGD) for diagnosis and treatment monitoring. We aimed to identify the frequency of endoscopic monitoring in children with EoE and observe the effect of age, race, socioeconomic factors, and atopy on the rate of endoscopy. METHODS We queried the Pediatric Health Information System over a 15-year period for ambulatory EGDs in children with EoE. Subjects with at least 1 year of data were included. Age, sex, ethnicity, race, insurance type, median household income, and atopy were collected for each subject. RESULTS 16,517 subjects were included (mean age 8.5 years). 3211 (19%) of subjects had ≥1 EGD per subject year (EGD/SY). Subjects >13 years old were more likely to have ≥1 EGD/SY compared to children 6-12 years (odds ratio [OR] 2.29, P < 0.001, 95% confidence interval [CI] = 2.06-2.54). Males were more likely to have ≥1 EGD/SY compared to females (OR 1.19, P < 0.001, 95% CI = 1.08-1.31). African-American subjects were 16% less likely than Caucasian subjects to have ≥1 EGD/SY (OR 0.84, P = 0.05, 95% CI = 0.71-1.00). Subjects with allergic rhinitis or anaphylaxis, food allergy, and/or oral allergy syndrome were more likely to have ≥1 EGD/SY (OR 1.67, P < 0.001, 95% CI = 1.47-1.90 and OR 3.65, P < 0.001, 95% CI = 3.25-4.11, respectively). CONCLUSIONS Nineteen percent of subjects had ≥1 EGD/SY. Older age, male sex, allergic rhinitis, and food allergies were associated with more frequent endoscopic monitoring in children with EoE. Caucasian subjects had more frequent endoscopy than African-American subjects. This study raises awareness about underrecognized variation in the care of children with EoE.
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25
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Sharma A, Eluri S, Philpott H, Lemberg DA, Dellon ES. EoE Down Under Is Still EoE: Variability in Provider Practice Patterns in Australia and New Zealand Among Pediatric Gastroenterologists. Dig Dis Sci 2021; 66:2301-2310. [PMID: 32816214 DOI: 10.1007/s10620-020-06534-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is likely variation in approach and management of patient with EoE due to lack of standardized care and variation in guidelines. We aimed to identify current practices regarding diagnosis and treatment in children with eosinophillic esophagitis (EoE) in Australia and New Zealand (ANZ). METHODS Information on current diagnostic and management approaches for pediatric EoE was collected via an online survey sent to pediatric gastroenterologists (pGE) in ANZ. We performed a cross-sectional study of pGE using a 49-question instrument regarding evaluation, diagnostic, and therapeutic aspects of EoE between October 2019 and December 2019. RESULTS Eighty-five percent of the survey responders were from Australia, and 66% were academic. 30% pGE perform > 3 esophageal biopsies for diagnosis of EoE, 40% involve an allergist, 30% use a twice daily PPI trial, and 70% do not exclude other cause of esophageal eosinophilia. For management, only 3% use dietary elimination as an initial therapy, and 24% use less than the recommended doses of swallowed fluticasone. Forty-nine percent were likely to stop treatment in after remission is achieved for 12 months. The EoE endoscopic reference score (EREFS) was not routinely used (49%). Two-thirds of pGE are concerned about long-term effects of recurrent need of general anesthesia. CONCLUSIONS Diagnostic and management strategies for EoE differed widely among pGE in ANZ, including in diagnostic biopsies, assessing competing causes of esophageal eosinophilia, initials selection of treatments, and maintenance strategies. This variability likely reflects continued uncertainty regarding optimal management strategies and stresses the need for pediatric-specific ANZ guidelines to standardize EoE care.
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Affiliation(s)
- Ajay Sharma
- Department of Paediatrics, St John of God Hospital, Midland, Perth, Australia. .,Curtin Medical School, Curtin University, Perth, WA, Australia. .,Perth Paediatrics, 5/2 McCourt Street, West Leederville, Perth, WA, Australia.
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
| | - Hamish Philpott
- Northern Adelaide Local Health Network, Department of Gastroenterology, University of Adelaide, Adelaide, SA, Australia
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital and School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
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26
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Chang JW, Rubenstein JH, Mellinger JL, Kodroff E, Strobel MJ, Scott M, Mack D, Book W, Sable K, Kyle S, Paliana A, Dellon ES. Motivations, Barriers, and Outcomes of Patient-Reported Shared Decision Making in Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:1808-1817. [PMID: 32621259 PMCID: PMC9110111 DOI: 10.1007/s10620-020-06438-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about patient choice in treatment of eosinophilic esophagitis (EoE). AIM Determine motivators and barriers to using common EoE therapies and describe patient-reported shared decision making (SDM) and satisfaction with treatment. METHODS We developed and administered a Web-based survey on factors influencing EoE treatment choice, SDM, and satisfaction. Adults with EoE and adult caregivers of pediatric EoE patients were recruited via patient advocacy groups and at two centers. Descriptive statistics of multiple response questions and multivariable logistic regression were performed to identify predictors of SDM and satisfaction with treatment. RESULTS A total of 243 adults (mean age 38.7 years) and 270 adult caregivers of children (mean age 9.5 years) completed the survey. Preventing worsening disease was the most common motivator to treat EoE. Barriers to topical steroids were potential side effects, cost, and preferring a medication-free approach. Inconvenience and quality of life were barriers to diet. Potential adverse events, discomfort, and cost were barriers to dilation. Nearly half (42%) of patients experienced low SDM, but those followed by gastroenterologists were more likely to experience greater SDM compared to non-specialists (OR 1.81; 95% CI 1.03-3.15). Patients receiving more SDM were more satisfied with treatment, regardless of provider or treatment type (OR 2.62, 95% CI 1.76-3.92). CONCLUSIONS Patients with EoE pursue treatment mostly to prevent worsening disease. Common barriers to treatment are inconvenience and financial costs. SDM is practiced most by gastroenterologists, but nearly half of patients do not experience SDM, indicating a substantial area of need in EoE.
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Affiliation(s)
- Joy W. Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Joel H. Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA,Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Jessica L. Mellinger
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Mary J. Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | | | - Denise Mack
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Wendy Book
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Kathleen Sable
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Scholeigh Kyle
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Allisa Paliana
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Evan S. Dellon
- Division of Gastroenterology, Center for Esophageal and Swallowing Disorders, University of North Carolina, Chapel‑Hill, NC, USA
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Chang JW, Haller E, Dellon ES. Dietary Management of Eosinophilic Esophagitis: Man Versus Food or Food Versus Man? Gastroenterol Clin North Am 2021; 50:59-75. [PMID: 33518169 DOI: 10.1016/j.gtc.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An alternative to pharmacologic management of eosinophilic esophagitis, elimination of food antigens for diet therapy is an effective first-line treatment strategy to induce and maintain symptomatic, histologic, and endoscopic disease remission. The 3 dietary strategies for eosinophilic esophagitis include elemental diet, empiric elimination diet, and targeted elimination diet. We review the studies supporting various diet therapy strategies, practical considerations and challenges for applying an elimination diet, and novel testing to identify triggers and optimize food reintroduction.
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Affiliation(s)
- Joy W Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA.
| | - Emily Haller
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB #7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
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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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29
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Jensen ET, Langefeld CD, Zimmerman KD, Howard TD, Dellon ES. Epigenetic methylation in Eosinophilic Esophagitis: Molecular ageing and novel biomarkers for treatment response. Clin Exp Allergy 2020; 50:1372-1380. [PMID: 32986922 DOI: 10.1111/cea.13748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Treatment failure in eosinophilic esophagitis (EoE) is common. We hypothesize that DNA methylation differs between patients by treatment response to topical steroids (oral viscous budesonide), thus offering the potential to inform targeting therapies. OBJECTIVE We sought to identify differentially methylated sites and affiliated genes in pre-treatment oesophageal cells between responders and non-responders and test for accelerated epigenetic ageing in oesophageal cells of EoE patients. METHODS DNA was extracted from prospectively collected and biobanked oesophageal biopsies from 36 Caucasian treatment naïve EoE patients at diagnosis. Methylation assays were completed using the Infinium HumanMethylation450 BeadChip. Normalized β values for each CpG site were tested (t test) for differential methylation. Further, 353 CpG probes were used to estimate epigenetic age for each patient and a linear regression model tested whether chronologic age and epigenetic age differed. Epigenetic age results were confirmed in an independent cohort of healthy controls. RESULTS Eighteen CpG sites were differentially methylated by treatment response (P < .00001). The mean epigenetic age and chronological age were 56.1 ± 11.1 and 36.7 ± 12.3 years, a mean age difference of 19.3 ± 5.2 years (P < .0001); accelerated ageing was not observed in the oesophageal cells of healthy controls. CONCLUSIONS AND CLINICAL RELEVANCE EoE patients that respond versus do not respond to treatment have differences in their methylation profile, including enrichment of genes in pathways consistent with cellular injury and repair due to environmental stress and cell adhesion and barrier integrity. EoE also appears to accelerate cellular ageing. Whether treatment can arrest or reverse accelerated epigenetic ageing and the implications for long-term disease progression is important areas for future research.
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Affiliation(s)
- Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Internal Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carl D Langefeld
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kip D Zimmerman
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy D Howard
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. J Pediatr Gastroenterol Nutr 2020; 71:83-90. [PMID: 32097371 DOI: 10.1097/mpg.0000000000002672] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. METHODS A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). RESULTS Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow-up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton-pump inhibitors (PPIs), topical steroids were the preferred second-line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first-line therapy, in contrast to most other countries. CONCLUSIONS Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.
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Miehlke S, Lucendo AJ, Straumann A, Jan Bredenoord A, Attwood S. Orodispersible budesonide tablets for the treatment of eosinophilic esophagitis: a review of the latest evidence. Therap Adv Gastroenterol 2020; 13:1756284820927282. [PMID: 32565912 PMCID: PMC7288799 DOI: 10.1177/1756284820927282] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/15/2020] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The incidence of EoE has increased substantially over the past two decades in Europe and North America. The natural course of EoE appears to be progressive with a high risk of stricture formation. The current European guideline recommend swallowed topical corticosteroids, proton-pump inhibitors or dietary intervention for initial and long-term treatment of EoE. Swallowed topical corticosteroids can be considered to be the best studied drug class in EoE, with more than 1000 patients enrolled in randomized clinical trials worldwide. In most of them, fluticasone or budesonide formulations have been used that were originally designed for asthma therapy, thus presumably suboptimal for EoE treatment. The new orodispersible budesonide tablet with effervescent properties is the first approved esophageal-targeted formulation specifically developed for the treatment of EoE, which has become available in many European countries. This article gives an overview of the evolution of topical corticosteroids in EoE and provides an update on recent data from large-scale multicenter trials exploring the efficacy and safety of the orodispersible budesonide tablet with effervescent properties in adult EoE patients.
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Affiliation(s)
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General
de Tomelloso, Tomelloso, Castilla-La Mancha, Spain
| | - Alex Straumann
- Department of Gastroenterology, Swiss EoE
Clinics, University Hospital Zurich, Zurich, Switzerland
| | - Albert Jan Bredenoord
- Department of Gastroenterology and Hepatology,
Academic Medical Center, Amsterdam, North Holland, The Netherlands
| | - Stephen Attwood
- Department of Health Services Research, Durham
University, Durham, UK
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Eluri S, Iglesia EGA, Massaro M, Peery AF, Shaheen NJ, Dellon ES. Practice patterns and adherence to clinical guidelines for diagnosis and management of eosinophilic esophagitis among gastroenterologists. Dis Esophagus 2020; 33:doaa025. [PMID: 32378700 PMCID: PMC7350163 DOI: 10.1093/dote/doaa025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
Real-world practice patterns of eosinophilic esophagitis (EoE) among gastroenterologists are not well-described. The aim is to describe practice patterns of EoE diagnosis and management and assess concordance with consensus guidelines. We conducted a cross-sectional online survey of gastroenterologists in the USA using Qualtrics, which was dispersed through the North Carolina Society of Gastroenterology (NCSG) and the American College of Gastroenterology member listservs. A similar survey was sent to NCSG members in 2010 and responses were compared in a subanalysis. Of 240 respondents, 37% (n = 80) worked in an academic setting versus 63% (n = 138) community practice setting. Providers saw a median of 18 (interquartile range 2-100) EoE patients annually and 24% (n = 52) were 'very familiar' with EoE guidelines. A proton-pump inhibitor (PPI) trial was required by 37% of providers prior to EoE diagnosis. In total, 60% used a ≥15 eosinophils per high-power field cut point for diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n = 28) followed EoE diagnosis guidelines. For first-line treatment, 7% used dietary therapy, 32% topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. In the NCSG cohort, a higher proportion in 2017 followed guideline diagnosis recommendations compared with 2010 (14% vs. 3%; P = 0.03) and a higher proportion used dietary therapy as first-line treatment (13% vs. 3%; P = 0.046). There is variability in EoE practice patterns for EoE management, with management differing markedly from consensus guidelines. Further education and guideline dissemination are needed to standardize practice.
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Affiliation(s)
- Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 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
| | - Edward G A Iglesia
- Division of Pediatric Allergy, Immunology, and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Massaro
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Anne F Peery
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 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
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 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
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 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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Management of eosinophilic esophagitis in children according to atopic status: A retrospective cohort in northeast of France. Arch Pediatr 2020; 27:122-127. [DOI: 10.1016/j.arcped.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/22/2019] [Accepted: 02/16/2020] [Indexed: 01/07/2023]
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Hannan N, Steel A, McMillan SS, Tiralongo E. Health Service Use and Treatment Choices for Pediatric Eosinophilic Esophagitis: Findings From a Cross-Sectional Survey of Australian Carers. Front Pediatr 2020; 8:147. [PMID: 32363170 PMCID: PMC7180181 DOI: 10.3389/fped.2020.00147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
Objectives: The incidence and the prevalence of eosinophilic esophagitis (EoE) are increasing, and healthcare utilization among children with EoE is high. This study provides novel insights into the health services and the treatments, including complementary medicines (CMs), used by carers to manage their children's EoE as well as the carers' beliefs and attitudes toward these treatments. Methods: A national cross-sectional online survey was conducted in Australia between September 2018 and February 2019. The survey included questions about health service and treatment utilization, health insurance and government support, health-related quality of life of children with EoE and their carers, views and attitudes toward CM use, and perceived efficacy of treatment. Results: The survey was completed by 181 carers (96.6% of whom were mothers) of EoE children. Most children (91.2%, n = 165) had seen a medical doctor for their EoE, and almost half had consulted with a CM practitioner (40.3%, n = 73). Pharmaceuticals (n = 156, 86.2%) were the most commonly used treatment option, followed by dietary changes (n = 142, 78.5%), CM products (n = 109, 60.2%), and CM therapies (n = 42, 23.2%). Most children received care from numerous practitioners on multiple occasions, indicating a substantial financial and treatment-related burden. Conclusions: A variety of practitioners are involved in the care of children with EoE, and a high rate of CM use warrants further attention to ensure that appropriate treatment is provided. Carer involvement and guidance, combined with individual practitioner expertise, referrals, and collaboration between providers, is essential to successfully navigate this complex disease and provide adequate care for these patients.
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Affiliation(s)
- Nicole Hannan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Amie Steel
- Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
| | - Sara S McMillan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Evelin Tiralongo
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
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