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Chan J, Flynn DM, Gordon M, Parmar R, Moolenschot K, Jackman L, Gaynor E, Epstein J, Cordell A, Kannappan H, Furman M, Thompson J, Gasparetto M, Auth MKH. Swallowed topical steroid therapy for eosinophilic oesophagitis in children: practical, evidence-based guidance by the BSPGHAN Eosinophilic Oesophagitis Working Group. BMJ Paediatr Open 2024; 8:e002467. [PMID: 38782481 PMCID: PMC11116858 DOI: 10.1136/bmjpo-2023-002467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE To develop evidence-based guidance for topical steroid use in paediatric eosinophilic oesophagitis (pEoE) in the UK for both induction and maintenance treatment. METHODS A systematic literature review using Cochrane guidance was carried out by the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) Eosinophilic Oesophagitis (EoE) Working Group (WG) and research leads to determine the evidence base for preparation, dosing and duration of use of swallowed topical steroid (STS) formulations in EoE. Seven themes relating to pEoE were reviewed by the WG, alongside the Cochrane review this formed the evidence base for consensus recommendations for pEoE in the UK. We provide an overview of practical considerations including treatment regimen and dosing. Oral viscous budesonide (OVB) and, if agreed by local regulatory committees, orodispersible budesonide (budesonide 1 mg tablets) were selected for ease of use and with most improvement in histology. A practical 'how to prepare and use' OVB appendix is included. Side effects identified included candidiasis and adrenal gland suppression. The use of oral systemic steroids in strictures is discussed briefly. RESULTS 2638 citations were identified and 18 randomised controlled trials were included. Evidence exists for the use of STS for induction and maintenance therapy in EoE, especially regarding histological improvement. Using the Appraisal of Guidelines, Research and Evaluation criteria, dosing of steroids by age (0.5 mg two times per day <10 years and 1 mg two times per day ≥10 years) for induction of at least 3 months was suggested based on evidence and practical consideration. Once histological remission is achieved, maintenance dosing of steroids appears to reduce the frequency and severity of relapse, as such a maintenance weaning regimen is proposed. CONCLUSION A practical, evidence-based flow chart and guidance recommendations with consensus from the EoE WG and education and research representatives of BSPGHAN were developed with detailed practical considerations for use in the UK.
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Affiliation(s)
- Joseph Chan
- Paediatric Gastroenterology, University Hospital of Wales, Cardiff, UK
| | - Diana M Flynn
- Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | | | - Raj Parmar
- Paediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Lucy Jackman
- Specialist Paediatric Dietitian, Great Ormond Street Hospital for Children, London, UK
| | - Ed Gaynor
- Paediatric Gastroenterology/Mucosal Immunology, Great Ormond Street Hospital for Children, London, UK
| | - Jenny Epstein
- Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | | | - Hema Kannappan
- General Paediatrics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mark Furman
- Paediatric Gastroenterology, Royal Free Hospital, London, UK
| | | | - Marco Gasparetto
- Paediatric Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Marcus K H Auth
- Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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2
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Lucendo A, Groetch M, Gonsalves N. Dietary Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:223-244. [PMID: 38575220 DOI: 10.1016/j.iac.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated food allergy-driven disease characterized by eosinophilic inflammation of the esophagus leading to symptoms of esophageal dysfunction. Prior studies have supported the key role of food allergen exposure as the main driver behind the etiopathogenesis showing that removal of food antigens can result in disease remission in both children and adults. These landmark studies serve as the basis for the rising interest and evolution of dietary therapy in EoE. This article will focus on the rationale for dietary therapy in EoE and provide helpful tools for the implementation of dietary therapy in practice.
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Affiliation(s)
- Alfredo Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd); Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Ciudad Real 13700, Spain
| | - Marion Groetch
- Department of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, 676 North St. Claire, Suite 1400, Chicago, IL 60611, USA.
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3
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Sharlin CS, Mukkada VA, Putnam PE, Bolton SM. Treatment of Pediatric Eosinophilic Esophagitis: Traditional and Novel Therapies. Curr Gastroenterol Rep 2023; 25:289-298. [PMID: 37658151 DOI: 10.1007/s11894-023-00893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE OF REVIEW This review presents and summarizes the existing studies on the treatment goals and options for pediatric eosinophilic esophagitis utilizing rigorous peer-reviewed literature. RECENT FINDINGS In addition to traditional treatments, emerging biologic therapies continue to evolve the approach to treating pediatric eosinophilic esophagitis. Well defined treatment goals will aid the continued development of new therapies. Further, innovative assessment tools have changed how the clinician is able to assess the effectiveness of therapies with a trend toward less invasive options. The management of pediatric eosinophilic esophagitis continues to evolve with the advent of both novel treatment options and assessment tools. Treatment choices, with benefits and risks involved, should be presented to families upon diagnosis and tailored towards the individual patient and likelihood of adherence and success. Biologic therapy for EoE presents an exciting option for both first line therapy and escalation for those with severe or unresponsive disease.
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Affiliation(s)
- Colby S Sharlin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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4
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Koenigsberg R, Gupta S, Slaven JE, Sarin T, Vitalpur G. Body mass index in relation to symptom presentation on diagnosis of eosinophilic esophagitis in children. Ann Allergy Asthma Immunol 2023; 131:482-486. [PMID: 37311509 DOI: 10.1016/j.anai.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The relationship between body mass index (BMI) and eosinophilic esophagitis (EoE) among children is not well characterized. OBJECTIVE To evaluate the presentations of EoE in pediatric patients of different weight classes. METHODS Records of newly diagnosed children with EoE at an academic center from 2015 to 2018 were evaluated regarding demographics, symptom presentation, and endoscopic findings and compared among the underweight, normal weight, overweight, and obese groups. RESULTS There were 341 patients aged 0 to 18 years old newly diagnosed with EoE from 2015 to 2018 (68.3% male, 233 of 341; 80.9% White, 276 of 341). Of the 341, 17 were underweight (4.9%), 214 normal weight (62.8%), 47 overweight (13.8%), and 63 obese (18.5%). Children with obese and overweight BMI were more likely to be diagnosed at an older age (P = .005) and to present with a chief complaint of abdominal pain (P = .02). Normal- and under-weight children were more likely to have an immunoglobulin E-mediated food allergy (P = .02). Normal weight children were more likely to be tested for food allergies (P = .02) and inhalant allergies (P = .004) and have linear furrows on endoscopy (P = .03), compared with children with overweight and obese BMI. No significant differences were found regarding race, sex, type of insurance, atopic dermatitis, asthma, or allergic rhinitis in relation to BMI status and EoE diagnosis. CONCLUSION Nearly one-third of children were obese or in overweight status on diagnosis with EoE. Children with BMI in the overweight or obese range were more likely to be older at diagnosis and to have a chief complaint of abdominal pain on presentation.
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Affiliation(s)
- Rebecca Koenigsberg
- Division of Allergy & Immunology, Nationwide Children's Hospital and the Ohio State University College of Medicine, Columbus, Ohio
| | - Sandeep Gupta
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Alabama at Birmingham, Birmingham, Alabama
| | - James E Slaven
- Department of Biostatistics and Public Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tara Sarin
- Allergy Associates of Utah, Murray, Utah
| | - Girish Vitalpur
- Division of Pediatric Pulmonology, Allergy-Immunology & Sleep Medicine, Riley Hospital for Children at Indiana University Health and the Indiana University School of Medicine, Indianapolis, Indiana.
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5
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Votto M, De Filippo M, Caimmi S, Indolfi C, Raffaele A, Tosca MA, Marseglia GL, Licari A. A Practical Update on Pediatric Eosinophilic Esophagitis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1620. [PMID: 37892285 PMCID: PMC10605219 DOI: 10.3390/children10101620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Eosinophilic esophagitis (EoE) is an emerging atopic disease of unknown etiology limited to the esophagus. The pathogenesis is still understood and is likely characterized by type 2 inflammation. Food allergens are the primary triggers of EoE that stimulate inflammatory cells through an impaired esophageal barrier. In children and adolescents, clinical presentation varies with age and mainly includes food refusal, recurrent vomiting, failure to thrive, abdominal/epigastric pain, dysphagia, and food impaction. Upper-gastrointestinal endoscopy is the gold standard for diagnosing and monitoring EoE. EoE therapy aims to achieve clinical, endoscopic, and histological ("deep") remission; prevent esophageal fibrosis; and improve quality of life. In pediatrics, the cornerstones of therapy are proton pump inhibitors, topical steroids (swallowed fluticasone and viscous budesonide), and food elimination diets. In recent years, much progress has been made in understanding EoE pathogenesis, characterizing the clinical and molecular heterogeneity, and identifying new therapeutic approaches. Notably, clinical, molecular, endoscopic, and histological features reflect and influence the evolution of inflammation over time and the response to currently available treatments. Therefore, different EoE phenotypes and endotypes have recently been recognized. Dupilumab recently was approved by FDA and EMA as the first biological therapy for adolescents (≥12 years) and adults with active EoE, but other biologics are still under consideration. Due to its chronic course, EoE management requires long-term therapy, a multidisciplinary approach, and regular follow-ups.
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Affiliation(s)
- Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Maria De Filippo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Silvia Caimmi
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Cristiana Indolfi
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Alessandro Raffaele
- Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | | | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
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Kumar A, Kompaniyets L, Belay B, Pierce SL, Grosse SD, Goodman AB. Body Mass Index and Associated Medical Expenditures in the US Among Privately Insured Individuals Aged 2 to 19 Years in 2018. JAMA Pediatr 2023; 177:827-836. [PMID: 37399028 PMCID: PMC10318546 DOI: 10.1001/jamapediatrics.2023.2012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/14/2023] [Indexed: 07/04/2023]
Abstract
Importance Nearly 40% of US youth aged 2 to 19 years do not have a body mass index (BMI) in the healthy weight category. However, there are no recent estimates for BMI-associated expenditures using clinical or claims data. Objective To estimate medical expenditures among US youth across all BMI categories along with sex and age groups. Design, Setting, Participants This cross-sectional study used IQVIA's ambulatory electronic medical records (AEMR) data set linked with IQVIA's PharMetrics Plus Claims database from January 2018 through December 2018. Analysis was performed from March 25, 2022, through June 20, 2022. It included a convenience sample of a geographically diverse patient population from AEMR and PharMetrics Plus. The study sample included privately insured individuals with a BMI measurement in 2018 and excluded patients with pregnancy-related visits. Exposure BMI categories. Main Outcomes and Measures Total medical expenditures were estimated using generalized linear model regression with γ distribution and log-link function. For out-of-pocket (OOP) expenditures, a 2-part model was used that included logistic regression to estimate the probability of positive expenditures followed by generalized linear model. Estimates were shown with and without accounting for sex, race and ethnicity, payer type, geographic region, age interacted with sex and BMI categories, and confounding conditions. Results The sample included 205 876 individuals aged 2 to 19 years; 104 066 were male (50.5%) and the median age was 12 years. Compared with those with healthy weight, total and OOP expenditures were higher for all other BMI categories. Differences in total expenditures were highest for those with severe obesity ($909; 95% CI, $600-$1218) followed by underweight ($671; 95% CI, $286-$1055) compared with healthy weight. Differences in OOP expenditures were highest for those with severe obesity ($121; 95% CI, $86-$155) followed by underweight ($117; 95% CI, $78-$157) compared with healthy weight. Having underweight was associated with higher total expenditures at ages 2 to 5 years and 6 to 11 years by $679 (95% CI, $228-$1129) and $1166 (95% CI, $632-$1700), respectively; having severe obesity was associated with higher total expenditures at ages 2 to 5 years, 6 to 11 years, and 12 to 17 years by $1035 (95% CI, $208-$1863), $821 (95% CI, $414-$1227), and $1088 (95% CI, $594-$1582), respectively. Conclusions and Relevance The study team found medical expenditures to be higher for all BMI categories when compared with those with healthy weight. These findings may indicate potential economic value of interventions or treatments aimed at reducing BMI-associated health risks.
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Affiliation(s)
- Ashutosh Kumar
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyudmyla Kompaniyets
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brook Belay
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Samantha L. Pierce
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott D. Grosse
- Office of the Director, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alyson B. Goodman
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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7
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Sindher SB, Barshow S, Tirumalasetty J, Arasi S, Atkins D, Bauer M, Bégin P, Collins MH, Deschildre A, Doyle AD, Fiocchi A, Furuta GT, Garcia-Lloret M, Mennini M, Rothenberg ME, Spergel JM, Wang J, Wood RA, Wright BL, Zuberbier T, Chin AR, Long A, Nadeau KC, Chinthrajah RS. The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders. J Allergy Clin Immunol 2023; 151:595-606. [PMID: 36872039 PMCID: PMC9993424 DOI: 10.1016/j.jaci.2023.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Abstract
Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.
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Affiliation(s)
- Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Suzanne Barshow
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Jyothi Tirumalasetty
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Stefania Arasi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dan Atkins
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maureen Bauer
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Philippe Bégin
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Antoine Deschildre
- CHU Lille, Université Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Lille, France
| | - Alfred D Doyle
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Glenn T Furuta
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maria Garcia-Lloret
- Department of Pediatrics, Division of Immunology, Allergy, and Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Maurizio Mennini
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - Robert A Wood
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Torsten Zuberbier
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Andrew R Chin
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif.
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8
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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: 21] [Impact Index Per Article: 21.0] [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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9
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Lucendo AJ, Molina-Infante J. Current treatment options and long-term outcomes in patients with eosinophilic esophagitis. Expert Rev Clin Immunol 2022; 18:859-872. [PMID: 35770955 DOI: 10.1080/1744666x.2022.2096591] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. AREAS COVERED Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. EXPERT OPINION Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
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10
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Nutritional and Psychological Considerations for Dietary Therapy in Eosinophilic Esophagitis. Nutrients 2022; 14:nu14081588. [PMID: 35458150 PMCID: PMC9025426 DOI: 10.3390/nu14081588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
The step-up empiric elimination diet, starting from one/two food groups of most local allergens remains the current gold standard for a dietary approach in eosinophilic esophagitis (EoE) patients. Milk, followed by wheat and egg, is the most frequent food that triggers EoE in pediatric and adult patients. Elimination diets, with restrictions over four food groups, may be limited to highly motivated patients, in which nutritional counseling is recommended. Malnourishment is uncommon in EoE patients and likely multifactorial (concomitant gastrointestinal eosinophilic disorders or IgE-mediated food allergies, feeding difficulties, abnormal feeding behavior). Avoidant/restrictive food intake disorder in EoE children on highly restrictive diets was lately described and may warrant specific psychological support. As for adults, quality of life may be impaired by symptom severity and dietary restrictions, aside from recently reported food impaction-related specific anxiety in up to 43% of patients. Severe symptoms, feeding dysfunction, and diet restrictions may negatively influence psychosocial adjustment for patients and their caregivers.
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Treatment of Eosinophilic Esophagitis: Diet or Medication? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3249-3256. [DOI: 10.1016/j.jaip.2021.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022]
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Votto M, De Filippo M, Olivero F, Raffaele A, Cereda E, De Amici M, Testa G, Marseglia GL, Licari A. Malnutrition in Eosinophilic Gastrointestinal Disorders. Nutrients 2020; 13:E128. [PMID: 33396413 PMCID: PMC7824578 DOI: 10.3390/nu13010128] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 12/18/2022] Open
Abstract
Primary eosinophilic gastrointestinal disorders (EGIDs) are emerging chronic/remittent inflammatory diseases of unknown etiology, which may involve any part of the gastrointestinal (GI) tract, in the absence of secondary causes of GI eosinophilia. Eosinophilic esophagitis is the prototype of eosinophilic gastrointestinal disorders and is clinically characterized by symptoms related to esophageal inflammation and dysfunction. A few studies have assessed the nutritional status of patients with eosinophilic gastrointestinal disorders, showing conflicting results. This review summarizes the current evidence on the nutritional status of patients with EGIDs, focusing on the pediatric point of view and also speculating potential etiological mechanisms.
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Affiliation(s)
- Martina Votto
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
| | - Maria De Filippo
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
| | - Francesca Olivero
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
| | - Alessandro Raffaele
- Pediatric Surgery Unit, Department of Maternal and Child Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Emanuele Cereda
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Mara De Amici
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
- Immuno-Allergology Laboratory of the Clinical Chemistry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Giorgia Testa
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
| | - Amelia Licari
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCSS-Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy; (M.V.); (M.D.F.); (F.O.); (M.D.A.); (G.T.); (G.L.M.)
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Prevalence and Predictors of Compromised Bone Mineral Density in Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2020; 71:764-770. [PMID: 32740533 PMCID: PMC8009279 DOI: 10.1097/mpg.0000000000002866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The aim of the study was to determine whether patients with eosinophilic esophagitis (EoE) have lower bone mineral density (BMD) than expected and if bone deficits are more pronounced in subgroups of patients according to comorbidities (atopic disease and joint hypermobility) or treatments (dietary restriction, medication exposure). STUDY DESIGN Retrospective chart review was performed to obtain clinical data, including length of diagnosis, comorbidities, and methods of treatment for patients with EoE ages 3 to 21 years who had a lumbar spine dual-energy x-ray absorptiometry scan performed between 2014 and 2017. BMD was standardized by calculation of age, sex, and race-specific z scores. RESULTS A total of 269 patients met study criteria. The mean BMD z score (-0.55, 95% confidence interval: -0.68, -0.42) was lower than expected (P < 0.0001), and the prevalence of low BMD z score (≤-2.0) was higher than expected (8.5%, 95% confidence interval: 5.2%-11.9%, P < 0.0001). In multivariable regression models, BMD z scores were -0.27 lower among those following an elimination diet and -0.65 lower among those with any lifetime use of a proton pump inhibitor (93% of the sample). There was no association with swallowed steroid use. CONCLUSIONS In our sample, pediatric patients with EoE had a slightly lower BMD z score compared to peers, and the prevalence of low BMD was higher than expected. Taken cautiously given the limitations of our sample, risk factors for bone deficits included any lifetime use of proton pump inhibitor and a restrictive elimination diet, but not swallowed steroid use. Larger prospective studies are needed to better characterize risk factors for low BMD to help inform screening, selection of therapies, and provide appropriate anticipatory guidance for patients with EoE.
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Gutiérrez-Junquera C, Zevit N. Dietary treatment of eosinophilic gastrointestinal disorders in children. Curr Opin Clin Nutr Metab Care 2020; 23:210-216. [PMID: 32068545 DOI: 10.1097/mco.0000000000000643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of recent developments on dietary treatment of eosinophilic gastrointestinal disorders (EGID) in children. RECENT FINDINGS Food antigens are the main triggers of eosinophilic esophagitis (EoE); however, currently available allergy tests cannot reliably identify eliciting antigens. Studies evaluating the six-food empiric elimination diet (6FED-milk, wheat/gluten, egg, soy/legumes, nuts and fish/seafood) have shown histological remission rates of 72%. Milk, egg, wheat/gluten, and, to a lesser extent, soy/legumes were the most frequent food triggers with only one or two culprit foods identified for most patients. A 4-food elimination strategy afforded a 64% remission rate. A step-up two-four-six food elimination diet generated a 43% remission rate at the two-food elimination stage, and similar reported rates for 4FED and 6FED. Endoscopic procedures were reduced by a 20% compared with 6FED. In a prospective study including 63 children, exclusive milk elimination has been effective in 44% of them. Controlled elimination and reintroduction with histological assessment is necessary. SUMMARY Dietary therapy of EoE has evolved from more restrictive to less restrictive diets to provide better balance between efficacy vs. nutritional deficiencies and quality of life. Data on efficacy of dietary therapy in other EGIDs are very scarce.
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Affiliation(s)
- Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, University Hospital Puerta de Hierro Majadahonda, Autonomous University of Madrid, Madrid, Spain
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gonsalves NP, Aceves SS. Diagnosis and treatment of eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145:1-7. [PMID: 31910983 PMCID: PMC6986782 DOI: 10.1016/j.jaci.2019.11.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is an eosinophil-rich, TH2 antigen-mediated disease of increasing pediatric and adult worldwide prevalence. Diagnosis requires greater than or equal to 15 eosinophils per high-power field on light microscopy. Symptoms reflect esophageal dysfunction, and typical endoscopic features include linear furrows, white plaques, and concentric rings. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. Therapies include proton pump inhibitors, elimination diets, and topical corticosteroids. Effective treatment can reverse tissue fibrosis in some patients, as well as decrease the rate of food impactions. Esophageal dilation might be required to increase luminal patency. The chronic nature of EoE necessitates long-term therapy to avoid disease recurrence and complications. This review serves the function of providing the current state-of-the-art diagnostic criteria and disease management for adult and pediatric EoE.
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Affiliation(s)
- Nirmala P Gonsalves
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Ill.
| | - Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, and Rady Children's Hospital, San Diego, Calif.
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Bashaw H, Schwartz S, Kagalwalla AF, Wechsler JB. Tutorial: Nutrition Therapy in Eosinophilic Esophagitis—Outcomes and Deficiencies. JPEN J Parenter Enteral Nutr 2019; 44:600-609. [DOI: 10.1002/jpen.1738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Hillary Bashaw
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Sally Schwartz
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Amir F. Kagalwalla
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
- Department of Pediatrics John H. Stroger Hospital of Cook County Chicago Illinois USA
- Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Joshua B. Wechsler
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
- Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois USA
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Dellon ES, Gupta SK. A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:2149-2160. [PMID: 30710696 PMCID: PMC6667323 DOI: 10.1016/j.cgh.2019.01.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
While the diagnosis and initial treatment of eosinophilic esophagitis are becoming more standardized, there are still major gaps in knowledge related to measuring treatment response. One such question centers on how to measure treatment response and what treatment endpoints should be. This impacts not only patient care and engagement in decision-making, but also the field of drug development. In addition, studies so far have use a myriad of treatment endpoints including over a dozen histologic endpoint criteria. This review will discuss the various stakeholders involved in assessment of treatment endpoints of a complex condition, including patients, practitioners and regulatory agencies, and the care settings in which treatment response is assessed, including routine clinical care, clinical trials, and observational studies. Potential parameters or treatment endpoints such as histology, symptoms, patient-reported outcomes, endoscopy, and biomarkers are discussed along with associated challenges and opportunities. A framework on how to define treatment outcomes is discussed and a conceptual approach treatment response is proposed. This takes into account histology, symptoms, and endoscopic findings and harnesses existing, validated tools. It includes definitions of nonresponse, complete normalization, and a graded response category between these 2 extremes, and also permits flexibility and latitude for modifications as newer knowledge emerges. In addition, ways to position the pediatric population in these endeavors are discussed as are future research directions.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, University of Illinois College of Medicine, Peoria, IL
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Collins CA, Palmquist J, Proudfoot JA, Qian A, Wangberg H, Khosh-Hemmat E, Dohil R, Aceves SS. Evaluation of long-term course in children with eosinophilic esophagitis reveals distinct histologic patterns and clinical characteristics. J Allergy Clin Immunol 2019; 144:1050-1057.e5. [PMID: 31255641 PMCID: PMC6820855 DOI: 10.1016/j.jaci.2019.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic and increasingly prevalent antigen-driven disease. There is a paucity of information on long-term course in children. OBJECTIVE We sought to understand the longitudinal trajectory of pediatric EoE during routine clinical care. METHODS We prospectively enrolled children into an EoE database and reviewed their medical and pathologic records over 13 years. RESULTS From 2011 to 2015, 146 children with EoE seen for their first visit at our center had 2 or more years of follow-up and 3 or more endoscopies over an average follow-up period of 5.13 years (range, 2-13 years). Longitudinal eosinophilic inflammation during treatment demonstrated 3 patterns over time. Children with less than 15 eosinophils/high-power field (hpf) for greater than 75% of their follow-up period were termed continuous responders (CRs). Children with waxing and waning inflammation of less than 15 eosinophils/hpf for less than 75% but 25% or more of the follow-up period were termed intermittent responders (IRs). Nonresponders (NRs) were defined as having less than 15 eosinophils/hpf for less than 25% of their follow-up. Fifty-nine (40%) of 146 patients were CRs, 65 (45%) of 146 were IRs, and 22 (15%) of 146 were NRs. CRs differed from IRs and NRs on the parameter of male/female ratio (1:1 in CRs, 4:1 in IRs, and 6:1 in NRs; P < .001) and in their initial response to any therapy, including proton pump inhibitors (P < .001). Endoscopic severity correlated with esophageal eosinophilia (r = 0.73, P < .001). On multivariate analysis, female sex and initial therapeutic response to medications or elimination diet were associated with long-term control of esophageal eosinophilia. CONCLUSIONS Long-term pediatric EoE followed 3 different longitudinal trajectories of inflammation. The long-term histologic groups differed significantly in biological sex and initial therapeutic response.
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Affiliation(s)
- Cathleen A Collins
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Jacob Palmquist
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - James A Proudfoot
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Altman Clinical Translational Research Institute, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Alex Qian
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif
| | - Hannah Wangberg
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif
| | - Emad Khosh-Hemmat
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Ranjan Dohil
- Division of Gastroenterology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Seema S Aceves
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif.
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Steinbach EC, Hernandez M, Dellon ES. Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1483-1495. [PMID: 30201096 PMCID: PMC6134874 DOI: 10.1016/j.jaip.2018.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.
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Affiliation(s)
- Erin C Steinbach
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michelle Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
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