1
|
Mayerhofer C, Kavallar AM, Aldrian D, Lindner AK, Müller T, Vogel GF. Efficacy of Elimination Diets in Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00078-2. [PMID: 36731591 DOI: 10.1016/j.cgh.2023.01.019] [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: 09/09/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) can be treated by proton pump inhibitors, topical corticosteroids, or dietary measures. This study systematically assessed the efficacy of 4 major dietary treatment regimens in EoE, updating the evidence presented in a meta-analysis from 2014. METHODS Electronic databases such as PubMed, Scopus, and Web of Science, and other sources were searched up to September 2022 to identify studies on dietary treatment of EoE. Based on histologic remission criteria, the efficacy of these treatments was pooled and analyzed with respect to the type of dietary regimen: 6-food elimination diet (SFED), 4-food elimination diet (FFED), 1-food elimination diet (OFED), and a targeted elimination diet (TED). Clinical response rates, food sensitization, and efficacies for a pediatric subpopulation were calculated. Influencing variables on efficacies were estimated via meta-regression analyses. RESULTS Thirty-four studies with 1762 patients met the inclusion criteria. The overall rate of histologic remission was 53.8% (95% CI, 48.0%-59.6%), and in the individual dietary groups was 61.3% (95% CI, 53.0%-69.3%) for SFED, 49.4% (95% CI, 32.5%-66.3%) for FFED, 51.4% (95% CI, 42.6%-60.1%) for OFED, and 45.7% (95% CI, 32.0%-59.7%) for TED. Dietary regimen and patient age did not significantly affect rates of histologic remission. The overall rate of clinical response was 80.8% (95% CI, 72.3%-88.2%), with response rates of 92.8% (95% CI, 81.2%-99.6%) for SFED, 74.1% (95% CI, 49.8%-92.6%) for FFED, 87.1% (95% CI, 58.4%-99.9%) for OFED, and 69.0% (95% CI, 50.2%85.3%) for TED. CONCLUSIONS Dietary therapy is an effective treatment for EoE patients of any age. The current results could support a trend toward less-restrictive dietary regimens as a primary treatment option.
Collapse
Affiliation(s)
- Christoph Mayerhofer
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Maria Kavallar
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Denise Aldrian
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Thomas Müller
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Friedrich Vogel
- Department of Paediatrics I, Medical University of Innsbruck, Innsbruck, Austria; Institute of Cell Biology, Medical University of Innsbruck, Innsbruck, Austria.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Votto M, Naso M, Clemente AM, De Filippo M, Gargiulo G, Granone V, Siri G, Marseglia GL, Licari A. Eosinophilic esophagitis an update in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022034. [PMID: 35666120 PMCID: PMC9494178 DOI: 10.23750/abm.v93is3.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022]
Abstract
Eosinophilic esophagitis (EoE) is an emerging antigen-mediated, inflammatory disease of unknown etiology. EoE affects about 1/2,000 patients in the United States (US), with a higher prevalence rate in adults (43.4/100,000) than in children (29.5/100,000), prevailing in Caucasians and male sex. EoE is a multifactorial disease typically characterized by type 2 inflammation. Pathogenesis is not entirely understood and is likely non-IgE mediated. Food allergens trigger EoE, stimulating the dysregulated immune cells through an impaired esophageal epithelial barrier. Clinical presentation of EoE depends on age and mainly includes food refusal, vomiting, abdominal or chest pain, dysphagia, and food impaction. Endoscopy is the gold standard to diagnose EoE. The goal of EoE therapy is to achieve clinical and histological remission to prevent esophageal fibrosis and improve patients' quality of life (QoL). Cornerstones of therapy are PPIs, topical steroids, and elimination diets. Over recent decades, research progress has been made in terms of a greater understanding of the EoE pathogenesis and new therapeutic approaches. However, there are still several unmet needs, such as non-invasive tools and biomarkers for monitoring the disease.
Collapse
Affiliation(s)
- Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matteo Naso
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Andrea Martina Clemente
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Ginevra Gargiulo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Veronica Granone
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giulia Siri
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
4
|
Votto M, De Filippo M, Lenti MV, Rossi CM, Di Sabatino A, Marseglia GL, Licari A. Diet Therapy in Eosinophilic Esophagitis. Focus on a Personalized Approach. Front Pediatr 2021; 9:820192. [PMID: 35127602 PMCID: PMC8812465 DOI: 10.3389/fped.2021.820192] [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: 11/22/2021] [Accepted: 12/27/2021] [Indexed: 12/11/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergic disease defined by a marked eosinophilic inflammation and symptoms of esophageal dysfunction. EoE is a heterogeneous disease and severely impacts the quality of life of affected patients. The current therapeutic management of EoE is based on two cornerstones: medication and diet therapy, both effective but limited by several critical issues. The choice of one or the other therapy might depend on the different disease phenotypes (allergic vs. non-allergic, inflammatory vs. fibro-stenotic), patient's age (adult vs. childhood-onset), food habits, patient/family preference, and familiar financial resource. Diet therapy is a successful treatment but limited by low patient adherence, the need for several endoscopies, food restrictions, psychosocial impact, and potential nutritional deficiencies. All these limitations could be effectively overcome with multidisciplinary and personalized management. This review summarizes the most recent evidence on the dietary elimination approaches and will provide a practical guide to clinicians in managing and implementing dietary therapy for patients with EoE.
Collapse
Affiliation(s)
- Martina Votto
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Carlo Maria Rossi
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- *Correspondence: Amelia Licari
| |
Collapse
|
5
|
Azzano P, Villard Truc F, Collardeau-Frachon S, Lachaux A. Children with eosinophilic esophagitis in real life: 10 years' experience with a focus on allergic management. Allergol Immunopathol (Madr) 2020; 48:244-250. [PMID: 31813622 DOI: 10.1016/j.aller.2019.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/26/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES Eosinophilic esophagitis (EoE) is frequently miss-diagnosed or overlooked for several years because of the invasiveness of investigations and the non-specificity of symptoms in childhood. Due to the lack of specific recommendations in children, its management remains very heterogeneous, especially concerning allergy testing. The aim of this study is to analyze our population and practices, in comparison with the literature, with a focus on allergic management, to harmonize and optimize our practice. MATERIAL AND METHODS We included all children with a diagnosis of EoE at the Hospital Femme Mere Enfant, Bron, France. Data were collected via retrospective chart review. RESULTS 108 patients were included with an average age of 9.5 years. Average delay before diagnosis was 6.65 years. Symptoms varied with age, with a predominance of vomiting (60% of patients), feeding difficulties (72%) and growth difficulties (24%) in children <5 years, whereas older children often presented with feeding blockage (64%) and dysphagia (61%). Cough was frequent in our cohort (18.5%), especially in children <10 years (38.5% between three and five years). The allergic background was frequent (70.3%) and 80% of our patients benefited from allergy testing. Allergy testing was particularly useful to guide therapy as elimination diet represented an effective treatment in 60% of our patients CONCLUSIONS: Allergy testing has to be harmonized to include major allergens (egg, milk, peanut, fish, wheat, and soy), including prick and patch tests. Allergy-testing based diet seemed to be the best compromise between efficiency and constraints, especially in mono-sensitized patients.
Collapse
|
6
|
Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124:424-440.e17. [PMID: 32336463 PMCID: PMC8171057 DOI: 10.1016/j.anai.2020.03.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
Collapse
Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy Immunology Center for Immunity, Infection, and Inflammation, University of California, San Diego Rady Children's Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
7
|
Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020; 158:1789-1810.e15. [PMID: 32359563 PMCID: PMC9473155 DOI: 10.1053/j.gastro.2020.02.039] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
Collapse
Affiliation(s)
- Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo
Clinic, Scottsdale, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s
Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of
Colorado School of Medicine, Aurora, Colorado
| | - Seema S. Aceves
- Division of Allergy Immunology Center for Immunity,
Infection, and Inflammation, University of California, San Diego Rady
Children’s Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s
Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M. Spergel
- Division of Allergy-Immunology, Children’s
Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland
Veterans Affairs Medical Center and University Hospitals, Case Western Reserve
University School of Medicine, Cleveland, Ohio
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of
Gastroenterology and Hepatology, University of North Carolina School of Medicine,
Chapel Hill, North Carolina
| | | | | | | | | |
Collapse
|
8
|
Lee J, Frey C, Miller J, Minard C, Noor M, Anagnostou A, Olive A, Davis CM, Anvari S. Skin testing with different food formulations in pediatric patients with eosinophilic esophagitis. Pediatr Allergy Immunol 2020; 31:329-332. [PMID: 31765019 DOI: 10.1111/pai.13181] [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] [Indexed: 10/25/2022]
Affiliation(s)
- Jessica Lee
- Baylor College of Medicine, Houston, TX, USA
| | | | - Jennifer Miller
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Charles Minard
- Dan L Duncan Institution for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Munazza Noor
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Aikaterini Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Anthony Olive
- Department of Pediatrics, Department of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Carla M Davis
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sara Anvari
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
9
|
Cavalli E, Brusaferro A, Pieri ES, Cozzali R, Farinelli E, De' Angelis GL, Esposito S. Eosinophilic esophagitis in children: doubts and future perspectives. J Transl Med 2019; 17:262. [PMID: 31399124 PMCID: PMC6688237 DOI: 10.1186/s12967-019-2014-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/04/2019] [Indexed: 01/07/2023] Open
Abstract
Background Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder and represents the leading cause of food impaction. The pathogenesis of EoE is the result of an interplay between genetic, environmental and host immune system factors. New therapeutic approaches for EoE have been proposed. In this manuscript we review the current evidence regarding EoE management in pediatric age, with a particular focus on new findings related to the efficacy and safety of monoclonal antibodies. Main body Conventional therapies have failed in treating some patients with EoE, which then requires aggressive procedures such as esophageal dilatation. The most effective available medical therapy for EoE is swallowed topic corticosteroids (fluticasone propionate and budesonide), which have two main drawbacks: they are related to well-known adverse effects (especially in the paediatric population), and there are not enough long-term data to confirm that they are able to reverse the remodelling process of the esophageal mucosa, which is the major cause of EoE symptoms (including dysphagia, abdominal pain, nausea, obstruction, perforation and vomiting). The monoclonal antibodies appear to be an interesting therapeutic approach. However, the studies conducted until now have shown substantial histological improvement not coupled with significant clinical improvements and no significant relationship between a decreasing number of eosinophils and clinical symptoms, highlighting the importance in the pathogenesis of EoE of cells such as T-helper cells, mast cells, B cells, epithelial cells and natural killer cells. Conclusions Monoclonal antibodies targeting a signal involved in the pathogenesis of EoE may not break the complex self-propagating inflammatory activation responsible for perpetuation of the inflammatory response and the development of symptoms and complications. We speculate that combined biological therapies targeting more than one molecule or cell may provide better results, with conventional therapies potentially enhancing the effects of antibodies. However, further studies should aim to find the best therapeutic approach to target the cells involved in the remodelling process and to reverse the histological changes in this complex clinical condition.
Collapse
Affiliation(s)
- Elena Cavalli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Andrea Brusaferro
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Elena Sofia Pieri
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Rita Cozzali
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Edoardo Farinelli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy.
| |
Collapse
|
10
|
Alterio T, Cardile S, Trayers C, Valenti S, Loddo I, Mardare R, Mosca A, Nobili V. Eosinophilic esophagitis in children: current knowledge to open new horizons. Scand J Gastroenterol 2019; 54:822-829. [PMID: 31535579 DOI: 10.1080/00365521.2019.1641214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic Esophagitis (EoE) is a chronic immune/antigen-mediated condition which is also driven by genetic and environmental factors. It has been deeply investigated over the last years and its incidence is widely increasing in childhood. Although atopic diseases are closely linked with EoE, it does not recognize a classical IgE-mediate immune pathogenesis but it is rather a T helper type 2 inflammatory process. Familial clustering supports genetic predisposition in EoE and recent advances in understanding the genetic basis for EoE may eventually translate into targeted management of the disease. EoE diagnosis is based on clinical symptoms, micro, and macroscopic findings along with exclusion of gastroesophageal reflux disease (GERD) evidence. Management of the disease encompasses both dietary and pharmacological solutions that need to be specifically targeted on patients' history, clinical symptoms, and diagnostic evaluations. New therapies, currently not available in children, may represent the basis for future therapeutic options in the next years.
Collapse
Affiliation(s)
- Tommaso Alterio
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Sabrina Cardile
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Claire Trayers
- Department of Paediatric and Perinatal Pathology, Cambridge University Hospitals (CUH), Addenbrooke's Hospital , Cambridge , UK
| | - Simona Valenti
- Department of Pediatrics, University of Messina , Messina , Italy
| | - Italia Loddo
- Department of Laboratory Medicine and Advanced Biotechnologies, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT) - IRCCS , Palermo , Italy
| | - Roxana Mardare
- Department of Pediatrics, Cambridge University Hospitals (CUH), Addenbrookes Hospital , Cambridge , UK
| | - Antonella Mosca
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Valerio Nobili
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy.,Department of Pediatrics, University "La Sapienza" , Rome , Italy
| |
Collapse
|
11
|
Mehr S, Brown-Whitehorn T. What do allergists in practice need to know about non-IgE-mediated food allergies. Ann Allergy Asthma Immunol 2019; 122:589-597. [PMID: 30935977 DOI: 10.1016/j.anai.2019.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Sam Mehr
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Allergy and Immunology, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology, Department of Pediatric, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Cianferoni A, Shuker M, Brown-Whitehorn T, Hunter H, Venter C, Spergel JM. Food avoidance strategies in eosinophilic oesophagitis. Clin Exp Allergy 2019; 49:269-284. [DOI: 10.1111/cea.13360] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| | - Michelle Shuker
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| | - Hannah Hunter
- Allergy; Guy's and Saint Thomas’ NHS Foundation Trust; London UK
| | - Carina Venter
- Allergy and Immunology; Children's Hospital Colorado; Aurora Colorado
| | - Jonathan M. Spergel
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| |
Collapse
|
13
|
Davis CM. Topical Steroids and Elimination Diets for EoE: Happier Together? Dig Dis Sci 2018; 63:2163-2164. [PMID: 29675661 DOI: 10.1007/s10620-018-5055-y] [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] [Indexed: 12/09/2022]
Affiliation(s)
- Carla M Davis
- Section of Immunology, Allergy and Rheumatology, Texas Children's Hospital Food Allergy Program, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Avenue, MC 330.01, Houston, TX, 77030, USA.
| |
Collapse
|
14
|
Combined and Alternating Topical Steroids and Food Elimination Diet for the Treatment of Eosinophilic Esophagitis. Dig Dis Sci 2018; 63:2381-2388. [PMID: 29380175 PMCID: PMC7063535 DOI: 10.1007/s10620-018-4931-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/11/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Few studies have examined combined or alternating treatment algorithms in eosinophilic esophagitis. AIMS We conducted a retrospective cohort study to ascertain the efficacy and adherence to a combined and alternating treatment approach with topical corticosteroids and 2-food elimination diet for pediatric EoE. METHODS Patients were prescribed a 2-food elimination diet (milk and soy) and topical corticosteroid (fluticasone or oral viscous budesonide) for 3 months, after which the steroid was discontinued and 2-food elimination diet continued for 3 months. An EGD was performed at baseline, 3 and 6 months. Clinical, endoscopic, and histologic data were extracted from electronic medical records. Nonparametric tests assessed adherence and outcomes. RESULTS Twenty-nine eosinophilic esophagitis cases were included (mean age 11.5 years, 61% male). Complete adherence to combined therapy and 2-food elimination diet alone was 75 and 79%, respectively. Median eosinophil counts decreased from 51 to 2 eosinophils/hpf (p < 0.001) after combined treatment and rebounded to 31 (p = 0.07) after 2FED alone. Dysphagia improved after both the combined and 2-food elimination diet alone treatment approaches (52 vs. 11% and 10%; p = 0.001, 0.005). Nonsignificant improvements in endoscopic findings were documented across the length of follow-up. CONCLUSIONS An initial combined treatment approach resulted in significant improvements in symptoms and histologic findings. While symptomatic improvements continued with 2-food elimination diet alone, the histologic improvement was not maintained. While loss to follow-up may obscure the efficacy of 2-food elimination diet alone, a combined/alternating treatment approach merits assessment in a larger prospective study.
Collapse
|
15
|
Chang JW, Yeow RY, Waljee AK, Rubenstein JH. Systematic review and meta-regressions: management of eosinophilic esophagitis requires histologic assessment. Dis Esophagus 2018; 31:5035741. [PMID: 29893826 PMCID: PMC9118332 DOI: 10.1093/dote/doy049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Treatment endpoints in eosinophilic esophagitis (EoE) are response of eosinophilic inflammation and of symptoms. Steroids and diet therapy are effective in inducing histologic response in EoE, but there may be poor correlation between histologic and symptomatic response. Despite this, we find that in clinical practice symptoms are commonly used to guide management without assessing histologic response. We hypothesized that symptom response alone is not reliable in assessing response to therapy and is confounded by endoscopic dilation. We conducted a systematic review and meta-regressions to estimate the association of histologic and symptomatic response, stratified by whether concurrent dilation was permitted. We performed a systematic search of PubMed, EMBASE, and Web of Science for studies describing both histologic and symptomatic responses to dilation, steroid, and diet therapies. We abstracted the proportion of histologic response and symptom response. Studies were stratified by whether dilation was permitted. We performed meta-regressions of the association between the proportions with histologic and symptomatic response, stratified by whether dilation was permitted. We identified 1359 articles, of which 62 articles were assessed for eligibility, and 23 were included providing data on 1202 patients with EoE. Unstratified meta-regression of histologic versus symptomatic response showed moderate association and large heterogeneity (inconsistency index [I2] = 89%). In adult studies in which dilation was allowed, there was weak association between symptomatic and histologic response (β1 = 0.21), minimal symptomatic response of 67% and the heterogeneity persisted, I2 = 77%. In studies that prohibited dilation, maximal symptomatic response was 72% and was moderately associated with histologic response (β1 = 0.39) with less heterogeneity, I2 = 59%. Studies of EoE that permit dilation obscure the relation between histologic and symptomatic response and have a high floor effect for symptomatic response. Studies that prohibit dilation demonstrate moderate association between histologic and symptomatic response, but have a ceiling effect for symptomatic response. Our results demonstrate that success of dietary or medical management for EoE cannot be judged by symptoms alone, and require histologic assessment, particularly if dilation has been performed.
Collapse
Affiliation(s)
- J W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - R Y Yeow
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - A K Waljee
- Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - J H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| |
Collapse
|
16
|
Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
Collapse
Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
| |
Collapse
|
17
|
Munoz-Persy M, Lucendo AJ. Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach. Eur J Pediatr 2018; 177:649-663. [PMID: 29549437 DOI: 10.1007/s00431-018-3129-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022]
Abstract
UNLABELLED Eosinophilic esophagitis (EoE) is a unique form of non-IgE-mediated food allergy characterized by esophageal eosinophilic infiltration that commonly causes dysphagia and food impaction in children and adolescents. Assessing the efficacy of dietary restrictions or drug therapies to achieve clinical and histologic resolution of EoE through randomized controlled trials and meta-analyses has resulted in new evidence-based guidelines. Avoiding food triggers is the only therapy targeting the cause of the disease. None of the currently available food allergy tests adequately predict food triggers for EoE. Exclusively feeding with an amino acid-based elemental diet and empiric six-food elimination diet (avoiding the six foods most commonly related with food allergy) has consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies are deterrents for implementation. Simpler and less restrictive empirical methods, like a four-food (milk, gluten-containing cereals, egg, legumes) or a two-food (milk and gluten) elimination diet, show encouraging results. Proton pump inhibitors are currently a first-line treatment, achieving histological remission and improvement of symptoms in 54.1 and 64.9% of pediatric EoE patients, respectively. The efficacy of topical corticosteroids in EoE assessed in several trials and summarized in meta-analyses indicates that budesonide and fluticasone propionate are significantly superior to placebos, both in decreasing eosinophil mucosal infiltration and in relieving symptoms. Owing to differences in drug delivery, viscous budesonide formulas seem to be the best pharmacological therapy for EoE. CONCLUSION Applying evidence-based therapies and a practical management algorithm provide an effective control of EoE. What is Known: • Eosinophilic esophagitis (EoE) now constitutes the main cause of dysphagia and food impaction in children, adolescents, and young adults. • Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment. What is New: • Therapeutic goals in children with EoE include resolution of esophageal symptoms, to cure esophageal inflammation (mucosal healing) and restore a proper esophageal caliber in case of fibrostenotic endoscopic findings. Avoiding iatrogenic drug effects and nutritional deficiencies, as well as maintaining an adequate quality of life, is also essential. • Novel evidence-based guidelines, endorsed by several European scientific societies, incorporate recent advances in knowledge from several randomized controlled trials and systematic reviews to provide the best standard of care to pediatric patients, by following simple management algorithms.
Collapse
Affiliation(s)
- Mery Munoz-Persy
- Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700 Tomelloso, Ciudad Real, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| |
Collapse
|