Treatment adherence in pediatric eosinophilic gastrointestinal disorders

Formulations of Topical Steroids in Eosinophilic Esophagitis-Current Treatment and Emerging Possibilities

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by eosinophilic inflammation and esophageal dysfunction symptoms. The recommended first-line treatment options are proton pump inhibitors and swallowed topical steroids (STS). However, current recommendations regarding STS are based on relatively few studies employing various doses and formulations. Our aim was to review the STS formulations currently used in the treatment of eosinophilic esophagitis, to demonstrate in a practical way the variety of exiting application methods, and to present emerging options for STS delivery to the esophagus. After the literature review, we established that the three most commonly used STS formulations include mist from an inhaler, viscous suspensions compounded with vehicles for oral use, and a recently introduced proprietary medication in the form of orodispersible tablets. Several drug delivery technologies with potential use in EoE are under investigation. To ensure optimal adherence, the choice of formulation should be based on efficacy, patient preferences and experience of the clinician, as well as current recommendations. Further studies are needed to compare the efficacy and acceptability of existing STS types, and to develop new, well-tolerated and effective drug formulations.

Disease Course and Treatment Response of Eosinophilic Gastrointestinal Diseases in Children With Liver Transplantation: Long-Term Follow-Up

INTRODUCTION

To describe the clinical and laboratory profile, natural course, treatment outcome, and risk factors of posttransplant esophageal and nonesophageal eosinophilic gastrointestinal disorders (EGIDs).

METHODS

All children (aged <18 years) who underwent liver transplantation, between 2011 and 2019, in a single transplant center with a follow-up period of 1 year or more posttransplant and with a history of posttransplant endoscopic evaluation were included in this study.

RESULTS

During the study period, 89 children met the inclusion criteria. Patients were followed for a median of 8.0 years. A total of 39 (44%) patients were diagnosed with EGID after transplantation. Of these, 29 (33%) had eosinophilic esophagitis (EoE), and 10 (11%) had eosinophilic gastritis, gastroenteritis or enterocolitis. In comparison with the non-EGID group, patients with EGID were younger at transplant (P ≤ 0.0001), transplanted more frequently due to biliary atresia (P ≤ 0.0001), and had higher rates of pretransplant allergy (P = 0.019). In the posttransplant period, they had higher rates of mammalian Target of Rapamycin inhibitor use (P = 0.006), Epstein-Barr virus viremia (P = 0.03), post-transplant lymphoproliferative disease (P = 0.005), and allergen sensitization (P ≤ 0.0001). In regression analysis, young age at transplant, age at diagnosis, pretransplant atopic dermatitis, and post-transplant lymphoproliferative disease were associated with an increased risk of EGID or EoE. Laboratory abnormalities such as anemia (P = 0.007), thrombocytosis (P = 0.012), and hypoalbuminemia (P = 0.031) were more commonly observed in the eosinophilic gastritis, gastroenteritis or enterocolitis group than in the EoE group. Following treatment, most patients had symptomatic resolution at 3 months and histologic resolution at 6 months postdiagnosis. Among the patients who had 5 years of follow-up, none recurred.

DISCUSSION

EGID is a common posttransplant diagnosis, which seems to affect patients who are transplanted earlier and who have pretransplant atopy. Posttransplant EGID is responsive to treatment, but as histologic remission occurs after symptomatic resolution, the decision to perform control endoscopy should be delayed.

Nonesophageal Eosinophilic Gastrointestinal Disorders: Clinical Care and Future Directions

Eosinophilic gastrointestinal disorders are a set of conditions with a wide range of clinical manifestations and treatment modalities. The disorders are suspected to result from an abnormal inflammatory response to allergen (s), and individuals may develop a relapsing or chronic disease, if the allergen is not eliminated. Mechanisms of disease pathogenesis, including the humoral immune response, need to be fully elucidated. A variety of therapies are used, although there is a lack of well-defined randomized, prospective studies. Other therapeutic options are needed as the current treatments have potential concerns; elimination diets may impair a child's quality of life, and corticosteroids have adverse risks with long-term use. We review what is known about nonesophageal eosinophilic gastrointestinal disorders, and discuss research investigations which need to be conducted to facilitate diagnosis and enhance treatment methods.

An algorithm for the classification of mRNA patterns in eosinophilic esophagitis: Integration of machine learning

BACKGROUND

Diagnostic evaluation of eosinophilic esophagitis (EoE) remains difficult, particularly the assessment of the patient's allergic status.

OBJECTIVE

This study sought to establish an automated medical algorithm to assist in the evaluation of EoE.

METHODS

Machine learning techniques were used to establish a diagnostic probability score for EoE, p(EoE), based on esophageal mRNA transcript patterns from biopsies of patients with EoE, gastroesophageal reflux disease and controls. Dimensionality reduction in the training set established weighted factors, which were confirmed by immunohistochemistry. Following weighted factor analysis, p(EoE) was determined by random forest classification. Accuracy was tested in an external test set, and predictive power was assessed with equivocal patients. Esophageal IgE production was quantified with epsilon germ line (IGHE) transcripts and correlated with serum IgE and the T_h2-type mRNA profile to establish an IGHE score for tissue allergy.

RESULTS

In the primary analysis, a 3-class statistical model generated a p(EoE) score based on common characteristics of the inflammatory EoE profile. A p(EoE) ≥ 25 successfully identified EoE with high accuracy (sensitivity: 90.9%, specificity: 93.2%, area under the curve: 0.985) and improved diagnosis of equivocal cases by 84.6%. The p(EoE) changed in response to therapy. A secondary analysis loop in EoE patients defined an IGHE score of ≥37.5 for a patient subpopulation with increased esophageal allergic inflammation.

CONCLUSIONS

The development of intelligent data analysis from a machine learning perspective provides exciting opportunities to improve diagnostic precision and improve patient care in EoE. The p(EoE) and the IGHE score are steps toward the development of decision trees to define EoE subpopulations and, consequently, will facilitate individualized therapy.

Eosinophilic Esophagitis: A Case Study of a 12-Year-Old Boy

Eosinophilic esophagitis is an underrecognized chronic condition in which symptoms of gastroesophageal reflux are accompanied by eosinophilia in the esophagus. This disorder affects both children and adults and is associated with a history of other atopic disorders, particularly food allergies. This case study discusses the epidemiology of eosinophilic esophagitis and the proper procedures for diagnosis, referral, and management using the dietary restrictions and pharmacologic treatment included in the clinical recommendations issued by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; the American Academy of Allergy, Asthma, and Immunology; and the American College of Gastroenterologists.

Prospective, comparative effectiveness trial of cow's milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease in which food antigens play a key role. Current therapeutic options are limited to long-term steroid medication and dietary elimination of multiple foods, each of which is challenging. Our objective was to compare single food elimination of cow's milk to swallowed fluticasone in pediatric EoE patients. This is a prospective, comparative effectiveness trial of newly diagnosed EoE patients (ages 2-18 years) treated with swallowed fluticasone (n = 24) or elimination of cow's milk (n = 20). The dual outcome measures of repeat esophageal biopsy (6-8 weeks) and change in Pediatric Quality of Life Inventor (PedsQL) EoE Module and Symptoms Scales were used to assess response to treatment. After 6-8 weeks of treatment, peak esophageal eosinophil counts decreased to below the threshold of 15 eosinophils/high-power field in 64% of patients treated with cow's milk elimination and 80% of patients treated with swallowed fluticasone (P = 0.4). Mean PedsQL EoE Module total scores (69 vs. 82; P < 0.005) and Total Symptoms scores (58 vs. 75; P = 0.001) showed significant improvement with cow's milk elimination. Among children treated with swallowed fluticasone, mean PedsQL EoE Module total scores (64 vs. 75; P < 0.05) and Total Symptoms scores (58 vs. 69; P < 0.01) were also significantly improved after 6-8 weeks of therapy. Removal of cow's milk from the diet is an effective single food elimination treatment for pediatric patients with EoE as assessed by statistically significant histologic and symptomatic improvement. Cow's milk elimination may be more desirable for EoE patients who do not want to take chronic, long-term steroid medications.

Adult versus pediatric eosinophilic esophagitis: important differences and similarities for the clinician to understand

Eosinophilic esophagitis (EoE) is recognized as a common, allergy-associated cause of chronic esophageal symptoms affecting both children and adults. Research has begun to shed light on its epidemiology with consistent results from various geographical areas. Differences in clinical presentation, endoscopic aspects and response to treatment have all been reported for patients of different ages, and the question as to whether adult and pediatric EoE are manifestations of a single entity or in fact two distinct disorders has been posed. The most relevant differences between pediatric and adult EoE come from evolutionary changes in the consequences of the disease, including fibrous remodeling, and the ability to express symptoms. However, most studies support a common pathogenesis and similar histopathological features for adult and pediatric patients, being the same diagnostic criteria applied to them. This article comprehensively reviews the most recently published information and addresses important questions about the natural history of EoE.

Behavioral feeding problems and parenting stress in eosinophilic gastrointestinal disorders in children

BACKGROUND

Children with eosinophilic gastrointestinal disorders (EGID) and their families are asked to adhere to dietary restrictions which can present significant daily challenges. However, little is known about child and family functioning and adaptation and the impact of psychosocial functioning (e.g., behavioral feeding problems) on adherence to dietary restrictions in this pediatric population.

METHODS

We conducted a gender- and age-matched case-control study wherein parents of children with EGID and healthy control children completed measures of behavioral feeding problems, parenting stress, and adherence to prescribed dietary restrictions.

RESULTS

Children with EGID (n = 92) have significantly higher levels of behavioral feeding problems than healthy controls (n = 89; t = 5.7, p < 0.001; t = 7.9, p < 0.001). In particular, younger children demonstrated higher levels of behavioral feeding problems than older children. While behavioral feeding problems were not predictive of adherence to dietary restriction recommendations, they were positively associated with parenting stress.

CONCLUSIONS

The study results indicate that, for families caring for a child with EGID, higher levels of behavioral feeding problems are associated with parent maladjustment or dysfunction. A multidisciplinary treatment team is needed to provide comprehensive psychosocial and feeding evaluations and treatment in EGID families.

Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disorder that responds to dietary therapy; however, data evaluating the effectiveness of dietary therapeutic strategies are limited.

OBJECTIVE

This study compared the effectiveness of 3 frequently prescribed dietary therapies (elemental, 6-food elimination, and skin prick and atopy patch-directed elimination diets) and assessed the remission predictability of skin tests and their utility in directing dietary planning.

METHODS

A retrospective cohort of proton-pump inhibitor-unresponsive, non-glucocorticoid-treated patients with eosinophilic esophagitis who had 2 consecutive endoscopic biopsy specimens associated with dietary intervention was identified. Biopsy histology and remissions (<15 eosinophils/high-power field) after dietary therapy and food reintroductions were evaluated.

RESULTS

Ninety-eight of 513 patients met the eligibility criteria. Of these 98 patients, 50% (n= 49), 27% (n= 26), and 23% (n= 23) received elemental, 6-food elimination, and directed diets, respectively. Remission occurred in 96%, 81%, and 65% of patients on elemental, 6-food elimination, and directed diets, respectively. The odds of postdiet remission versus nonremission were 5.6-fold higher (P= .05) on elemental versus 6-food elimination diets and 12.5-fold higher (P= .003) on elemental versus directed diets and were not significantly different (P= .22) on 6-food elimination versus directed diets. After 116 single-food reintroductions, the negative predictive value of skin testing for remission was 40% to 67% (milk, 40%; egg, 56%; soy, 64%; and wheat, 67%).

CONCLUSION

All 3 dietary therapies are effective; however, an elemental diet is superior at inducing histologic remission compared with 6-food elimination and skin test-directed diets. Notably, an empiric 6-food elimination diet is as effective as a skin test-directed diet. The negative predictive values of foods most commonly reintroduced in single-food challenges are not sufficient to support the development of dietary advancement plans solely based on skin test results.