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Walgraeve S, Vanuytsel T. Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence? Acta Gastroenterol Belg 2023; 86:437-448. [PMID: 37814560 DOI: 10.51821/86.3.11757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Background and study aims Eosinophilic esophagitis (EoE) is a food allergen-induced disease of the esophagus. Chronic, eosinophil-predominant inflammation eventually leads to fibrosis, esophageal dysfunction and severe morbidity. Swallowed topical corticosteroids (STCs) are a mainstay of anti-inflammatory therapy in the treatment of active EoE. Data on the efficacy of novel corticosteroid formulations, developed specifically for esophageal delivery, have recently become available. Methods A comprehensive review was performed aiming to summarize evidence on the role of STCs in the treatment of EoE. Two biomedical bibliographic databases (PubMED, EMBASE) were searched for articles providing original information on the efficacy and safety of STCs in adult EoE patients. Results Budesonide orodispersible tablet (BOT) and budesonide oral suspension (BOS) both surpassed placebo formulations regarding the efficacy of inducing and maintaining histologic, symptomatic and endoscopic remission. Overall, BOT displayed the highest grade of efficacy with clinico-histologic remission rates up to 75% after 1 year. Fluticasone propionate (APT-1011) achieved and maintained histologic and endoscopic responses in the majority of patients, whereas only a positive trend was demonstrated for symptomatic improvement. Mometasone and ciclesonide were studied in a limited number of smaller-scale trials and placebo-controlled data are required to substantiate the promising findings. All STCs displayed a similar side effects profile and were generally considered safe and well-tolerated. Conclusions Current evidence supports long-term treatment with novel corticosteroid formulations, challenging the established treatment paradigm of EoE. BOT appears to be the most effective steroid therapy, although head-to-head comparative trials between STCs are needed.
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Affiliation(s)
- S Walgraeve
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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2
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Lorenz NJ, Link A, Czapiewski P, Arnim UV. Eosinophilic esophagitis: Comparison of clinical, endoscopic and histological scoring systems. ZEITSCHRIFT FÜR GASTROENTEROLOGIE 2022; 60:1779-1786. [DOI: 10.1055/a-1855-1974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background Eosinophilic Esophagitis (EoE) has received increasing attention as a disease entity, and it is now recognized as an important disorder of the Upper Gastrointestinal Tract. Topical corticosteroids (tCS) are effective in clinical-pathological remission induction (RI) and remission maintenance (RM) of active EoE. With scoring systems, such as clinical (SDI), endoscopic (EREFS), and histological (EoEHSS) systems, EoE can be graded, and its disease activity can be assessed.
Objective To discover how closely results within each of the three scoring systems SDI, EREFS, and EoEHSS are correlated between initial diagnosis (ID), RI, and RM, and to determine how well scores from the three systems are intercorrelated at each time point.
Methods Retrospective cohort analysis of patients with active EoE was performed between 2006 and 2020, with follow-up for up to 6 years. SDI, EREFS and EoEHSS scores were recorded at ID, at RI, and in RM. Evaluation employed descriptive statistics, the Friedman test, and Bonferroni-corrected post hoc pairwise comparisons.
Results At RI 29 and at RM 19 EoE patients provided data. Significant correlations were found between EREFS and EoEHSS at RI and in RM. Pairwise comparisons showed significant differences between ID and RI for SDI, for EREFS, and for EoEHSS.
Conclusion The scoring systems tested did not show intercorrelation at ID. Comparison revealed significant differences for SDI, EREFS, and EoEHSS between the systems at ID und RI, but not in RM, during tCS treatment. These results underline the efficacy of tCS (at RI and RM) in the treatment of active EoE.
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Affiliation(s)
- Nikolas Johannes Lorenz
- Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Alexander Link
- Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Piotr Czapiewski
- Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
- Pathologie, Städtisches Klinikum Dessau, Dessau, Germany
| | - Ulrike von Arnim
- Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
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3
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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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4
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Miehlke S, Schlag C, Lucendo AJ, Biedermann L, Vaquero CS, Schmoecker C, Hayat J, Hruz P, Ciriza de los Rios C, Bredenoord AJ, Vieth M, Schoepfer A, Attwood S, Mueller R, Burrack S, Greinwald R, Straumann A. Budesonide orodispersible tablets for induction of remission in patients with active eosinophilic oesophagitis: A 6-week open-label trial of the EOS-2 Programme. United European Gastroenterol J 2022; 10:330-343. [PMID: 35412032 PMCID: PMC9004242 DOI: 10.1002/ueg2.12220] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND A novel budesonide orodispersible tablet (BOT) has been proven effective in adult patients with active eosinophilic oesophagitis (EoE) in a 6-week placebo-controlled trial (EOS-1). AIMS To report the efficacy of an open-label induction treatment with BOT in a large prospective cohort of EoE patients within the EOS-2 study. METHODS Patients with clinico-histological active EoE were treated with BOT 1 mg BID for 6 weeks. The primary endpoint was clinico-histological remission (≤2 points on numerical rating scales [0-10] each for dysphagia and odynophagia, and peak eosinophil count <16 eos/mm2 hpf (corresponds to <5 eos/hpf)). Further study endpoints included clinical and histological remission rates, change in the EEsAI-PRO score, change in peak eosinophil counts, and deep endoscopic remission using a modified Endoscopic Reference Score. RESULTS Among 181 patients enrolled, 126 (69.6%) achieved clinico-histological remission (histological remission 90.1%, clinical remission 75.1%). The mean peak eosinophil counts decreased by 283 eos/mm2 hpf (i.e., by 89.0%). Mean EEsAI-PRO score decreased from baseline by 29 points and deep endoscopic remission was achieved in 97 (53.6%) patients. The majority of patients judged tolerability as good or very good (85.6%) and compliance was high (96.5%). Local candidiasis was suspected in 8.3% of patients; all were of mild severity, resolved with treatment and none led to premature withdrawal from the study. CONCLUSIONS In this large prospective trial, a 6-week open-label treatment with BOT 1 mg BID was highly effective and safe in achieving clinico-histological remission of active EoE and confirmed the results of the placebo-controlled EOS-1 trial.
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Affiliation(s)
- Stephan Miehlke
- Centre for Digestive DiseasesInternal Medicine Centre EppendorfHamburgGermany
- Centre for Oesophageal DisordersUniversity Hospital EppendorfHamburgGermany
| | - Christoph Schlag
- II. Medizinische KlinikKlinikum rechts der IsarTU MünchenMünchenGermany
| | - Alfredo J. Lucendo
- Department of GastroenterologyHospital General de TomellosoTomellosoSpain
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd)BarcelonaSpain
- Instituto de Investigación Sanitaria PrincesaMadridSpain
| | - Luc Biedermann
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Cecilio Santander Vaquero
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd)BarcelonaSpain
- Instituto de Investigación Sanitaria PrincesaMadridSpain
- Department of Gastroenterology and HepatologyHospital Universitario de La PrincesaMadridSpain
| | - Christoph Schmoecker
- Klinik für Innere Medizin 1Sana Klinikum LichtenbergBerlinGermany
- Medizinische Hochschule BrandenburgCampus Ruppiner KlinikenMedizinische Klinik BNeuruppinGermany
| | - Jamal Hayat
- Department of GastroenterologySaint George's University Hospitals NHS TrustLondonUK
| | - Petr Hruz
- Clarunis, University Centre for Liver and Gastrointestinal DiseasesSt. Clara Hospital and University Hospital BaselBaselSwitzerland
| | | | - Albert Jan Bredenoord
- Department of Gastroenterology and HepatologyAcademic Medical CentreAmsterdamthe Netherlands
| | - Michael Vieth
- Institute for PathologyFriedrich‐Alexander‐University Erlangen‐NurembergKlinikum BayreuthBayreuthGermany
| | - Alain Schoepfer
- Department of Gastroenterology and HepatologyCentre Hospitalier Universitaire Vaudois and University of LausanneLausanneSwitzerland
| | - Stephen Attwood
- Department of Health Services ResearchDurham UniversityDurhamUK
| | - Ralph Mueller
- Department of Clinical Research & DevelopmentDr. Falk Pharma GmbHFreiburgGermany
| | - Sarah Burrack
- Department of Clinical Research & DevelopmentDr. Falk Pharma GmbHFreiburgGermany
| | - Roland Greinwald
- Department of Clinical Research & DevelopmentDr. Falk Pharma GmbHFreiburgGermany
| | - Alex Straumann
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
- Swiss EoE Research GroupOltenSwitzerland
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Young E, Philpott H. Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management. Dig Dis Sci 2022; 67:1101-1115. [PMID: 35230577 PMCID: PMC8976791 DOI: 10.1007/s10620-022-07419-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/20/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.
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Affiliation(s)
- Edward Young
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
| | - Hamish Philpott
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
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6
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Tytor J, Larsson H, Bove M, Johansson L, Bergquist H. Topically applied mometasone furoate improves dysphagia in adult eosinophilic esophagitis - results from a double-blind, randomized, placebo-controlled trial. Scand J Gastroenterol 2021; 56:629-634. [PMID: 33831327 DOI: 10.1080/00365521.2021.1906314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Topical corticosteroids are considered a cornerstone in the treatment of patients with eosinophilic esophagitis. The aim of this study was to evaluate the benefit of using mometasone furoate spray versus placebo on dysphagia and health-related quality of life in these patients. MATERIAL AND METHODS Consecutive, newly diagnosed adult patients with eosinophilic esophagitis were randomized and treated with either 200 micrograms of orally administered topical mometasone furoate or placebo 4 times daily for 8 weeks. Symptoms and quality of life were evaluated using questionnaires including the Watson Dysphagia Scale, the European Organization for Research and Treatment of Cancer Quality of Life-Oesophageal Module 18 and the Short Form-36 before and after treatment. RESULTS In the intention-to-treat analysis (n = 36) the Watson Dysphagia Scale score after mometasone treatment was reduced by 6.5 (median, p < .01) compared with 0 (median, ns) in the placebo group. The benefit of mometasone over placebo was significant (p < .05). In the per-protocol analysis (n = 33) the Watson Dysphagia Scale score was reduced by 5 (median, p = .01) after mometasone treatment compared with 0 (median, ns) in the placebo group. The advantage of mometasone over the placebo was significant (p < .05). The benefit of using mometasoneas evaluated by the two quality of life questionnaires was, however, insignificant. CONCLUSIONS Our finding suggests that in adult patients with eosinophilic esophagitis, topical mometasone furoate exerts a beneficial effect compared with placebo regarding the main symptom, i.e., dysphagia. A corresponding benefit could not be verified regarding the various quality of life measurements. CLINICAL TRIAL REGISTRATION Mometasone-furoate for Treatment of Eosinophilic Esophagitis - a Randomized Placebo Controlled Study ClinicalTrials.gov Identifier (NCT02113267).
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Affiliation(s)
- Jakob Tytor
- Department of Otorhinolaryngology, NU Hospital Group, Trollhättan, Sweden
| | - Helen Larsson
- Department of Otorhinolaryngology, NU Hospital Group, Trollhättan, Sweden
| | - Mogens Bove
- Department of Otorhinolaryngology, NU Hospital Group, Trollhättan, Sweden
| | - Leif Johansson
- Department of Otorhinolaryngology, Skaraborg Hospital, Skövde, Sweden
| | - Henrik Bergquist
- Department of ENT/H&N Surgery, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
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7
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Patient-Reported Dysphagia in Adults with Eosinophilic Esophagitis: Translation and Validation of the Swedish Eosinophilic Esophagitis Activity Index. Dysphagia 2021; 37:286-296. [PMID: 33686463 PMCID: PMC8948105 DOI: 10.1007/s00455-021-10277-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/18/2021] [Indexed: 12/11/2022]
Abstract
The lack of a Swedish patient-reported outcome instrument for eosinophilic esophagitis (EoE) has limited the assessment of the disease. The aims of the study were to translate and validate the Eosinophilic Esophagitis Activity Index (EEsAI) to Swedish and to assess the symptom severity of patients with EoE compared to a nondysphagia control group. The EEsAI was translated and adapted to a Swedish cultural context (S-EEsAI) based on international guidelines. The S-EEsAI was validated using adult Swedish patients with EoE (n = 97) and an age- and sex-matched nondysphagia control group (n = 97). All participants completed the S-EEsAI, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Oesophageal Module 18 (EORTC QLQ-OES18), and supplementary questions regarding feasibility and demographics. Reliability and validity of the S-EEsAI were evaluated by Cronbach’s alpha and Spearman correlation coefficients between the domains of the S-EEsAI and the EORTC QLQ-OES18. A test–retest analysis of 29 patients was evaluated through intraclass correlation coefficients. The S-EEsAI had sufficient reliability with Cronbach’s alpha values of 0.83 and 0.85 for the “visual dysphagia question” and the “avoidance, modification and slow eating score” domains, respectively. The test–retest reliability was sufficient, with good to excellent intraclass correlation coefficients (0.60–0.89). The S-EEsAI domains showed moderate correlation to 6/10 EORTC QLQ-OES18 domains, indicating adequate validity. The patient S-EEsAI results differed significantly from those of the nondysphagia controls (p < 0.001). The S-EEsAI appears to be a valid and reliable instrument for monitoring adult patients with EoE in Sweden.
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8
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Lingblom C, Albinsson S, Johansson L, Larsson H, Wennerås C. Patient-Reported Outcomes and Blood-Based Parameters Identify Response to Treatment in Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:1556-1564. [PMID: 32495256 PMCID: PMC8053156 DOI: 10.1007/s10620-020-06368-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Noninvasive methods to assess treatment response in eosinophilic esophagitis are needed. AIMS Our aim was to determine whether a blood-based biomarker panel centered on immune parameters could identify histologic response to treatment in eosinophilic esophagitis patients. METHODS A pilot study involving adult patients with active eosinophilic esophagitis recruited at two Ear, Nose, Throat clinics in Sweden was designed. The patients (n = 20) donated blood and esophageal biopsies and filled in three questionnaires before and after a 2-month course of topical corticosteroids. Blood samples were analyzed for absolute levels of granulocytes and T cells and the fractions of eosinophils expressing 10 different surface markers by flow cytometry. All data were analyzed by multivariate methods of pattern recognition. RESULTS Multivariate modeling revealed that a combination of 13 immune parameters and 10 patient-reported outcome scores were required to create a model capable of separating responders (n = 15) from non-responders (n = 5). Questions regarding symptoms of esophageal dysfunction and capacity to eat certain foods from two of the questionnaires were discriminatory in the multivariate model, as were absolute counts of T cells, eosinophils, and eosinophil expression of activation markers and cell adhesion molecules. CONCLUSIONS A combination of blood-based immune parameters and directed questions may prove helpful to monitor response to treatment, perhaps reducing the need for repeat endoscopies in eosinophilic esophagitis patients in the future.
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Affiliation(s)
- Christine Lingblom
- grid.8761.80000 0000 9919 9582Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Guldhedsgatan 10A, 413 46 Göteborg, Sweden ,grid.1649.a000000009445082XDepartment of Clinical Microbiology, Sahlgrenska University Hospital, Göteborg, Region Västra Götaland Sweden
| | - Sofie Albinsson
- grid.8761.80000 0000 9919 9582Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Guldhedsgatan 10A, 413 46 Göteborg, Sweden
| | - Leif Johansson
- Department of ENT, Head and Neck Surgery, Skövde County Hospital, Skaraborgs Sjukhus, Lövängsvägen, 541 42 Skövde, Sweden
| | - Helen Larsson
- grid.459843.70000 0004 0624 0259Department of ENT, Head and Neck Surgery, NU Hospital Group, Lärketorpsvägen, 461 73 Trollhättan, Sweden
| | - Christine Wennerås
- grid.8761.80000 0000 9919 9582Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Guldhedsgatan 10A, 413 46 Göteborg, Sweden ,grid.1649.a000000009445082XDepartment of Clinical Microbiology, Sahlgrenska University Hospital, Göteborg, Region Västra Götaland Sweden
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9
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Chernetsova E, Agarwal A, Weir A, Oltean I, Barkey J, Demellawy DE. Diagnostic Value of Mid-esophageal Biopsies in Pediatric Patients With Eosinophilic Esophagitis. Pediatr Dev Pathol 2021; 24:34-42. [PMID: 33496644 DOI: 10.1177/1093526620961359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is histologically defined as the presence of 15 or more intraepithelial eosinophils per high-power fields. Limited consensus exists on where to sample the esophagus in pediatrics. This study aimed to identify whether endoscopic and histologic examination of the mid esophagus offers diagnostic value compared to proximal/distal esophageal biopsies. METHODS A retrospective chart review of pediatric patients with EoE was performed. Endoscopic and histologic parameters were assessed at the initial and follow-up visits, and concordance between proximal/distal biopsy and mid biopsy was determined. RESULTS A total of 100 patients with a mean age of 9.6 ± 4.07 years were included. Endoscopic parameters between proximal/distal and mid esophagus were concordant in 84% to 97% of patients (initial assessment) and in 80% to 97% of patients (at follow-up). Mid esophagus showed endoscopic abnormalities, which were absent at the proximal/distal esophagus in 1% to 5% of patients, as well as histologic abnormalities in 2% to 8% of patients overall at initial and follow-up examinations. CONCLUSIONS We recommend continued endoscopic and histologic assessment of the proximal/distal biopsy; however, examination of the mid esophagus does offer small diagnostic value in our subset of patients. Future studies need to be conducted before conclusive recommendations supporting the use of mid-esophageal biopsies can be made.
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Affiliation(s)
- Elizaveta Chernetsova
- Department of Pathology, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amisha Agarwal
- Department of Pathology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Arielle Weir
- Department of Pathology, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pathology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Irina Oltean
- Department of Pathology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Janet Barkey
- Department of Pathology, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Dina El Demellawy
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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10
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Lucendo AJ. Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies. Expert Rev Clin Immunol 2020; 16:63-77. [PMID: 31842634 DOI: 10.1080/1744666x.2019.1705784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.
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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), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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11
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Lucendo AJ, Miehlke S, Schlag C, Vieth M, von Arnim U, Molina-Infante J, Hartmann D, Bredenoord AJ, Ciriza de Los Rios C, Schubert S, Brückner S, Madisch A, Hayat J, Tack J, Attwood S, Mueller R, Greinwald R, Schoepfer A, Straumann A, Vanuytsel T, Louis H, Musala C, Miehlke S, Frederking D, Bajbouj M, Schlag C, Nennstiel S, Brückner S, Schmelz R, Heimerl S, Stephan AM, Fibbe C, Liedtke (née Laschinsky) N, Keller J, Rosien U, Haag S, Schneider A, Hartmann D, Schmöcker C, Buchholz H, Lammert F, Casper M, Reichert M, Madisch A, Sommer D, Mönnikes H, Stengel M, Schmidtmann M, Müller M, Eckardt A, Wehrmann T, Schubert S, Armerding P, Hofmann WP, Liceni T, von Arnim U, Kandulski A, Weigt J, Börner N, Lutz-Vorderbrügge A, Albert J, Zeuzem S, Blumenstein I, Sprinzl K, Hausmann J, Bredenoord A, Bredenoord A, Warners M, Villarin AL, Arias ÁA, Tejero Bustos MÁ, Carrillo Ramos MJ, Olalla Gallardo JM, Tosina RJ, Molina-Infante J, Zamorano J, Vaquero CS, Francés SC, Pérez T, Rodriguez T, Ciriza de los Ríos C, Rodríguez-Valcárcel FC, Castel de Lucas I, Juan AP, Barenys M, Pons C, Martinez IP, Lauret ME, García AC, Rubio E, Straumann A, Hruz P, Brunner S, Hayat J, Poullis A. Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial. Gastroenterology 2019; 157:74-86.e15. [PMID: 30922997 DOI: 10.1053/j.gastro.2019.03.025] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Swallowed topical-acting corticosteroids are recommended as first-line therapy for eosinophilic esophagitis (EoE). Asthma medications not optimized for esophageal delivery are sometimes effective, although given off-label. We performed a randomized, placebo-controlled trial to assess the effectiveness and tolerability of a budesonide orodispersible tablet (BOT), which allows the drug to be delivered to the esophagus in adults with active EoE. METHODS We performed a double-blind, parallel study of 88 adults with active EoE in Europe. Patients were randomly assigned to groups that received BOT (1 mg twice daily; n = 59) or placebo (n = 29) for 6 weeks. The primary end point was complete remission, based on clinical and histologic factors, including dysphagia and odynophagia severity ≤2 on a scale of 0-10 on each of the 7 days before the end of the double-blind phase and a peak eosinophil count <5 eosinophils/high power field. Patients who did not achieve complete remission at the end of the 6-week double-blind phase were offered 6 weeks of open-label treatment with BOT (1 mg twice daily). RESULTS At 6 weeks, 58% of patients given BOT were in complete remission compared with no patients given placebo (P < .0001). The secondary end point of histologic remission was achieved by 93% of patients given BOT vs no patients given placebo (P < .0001). After 12 weeks, 85% of patients had achieved remission. Six-week and 12-week BOT administration were safe and well tolerated; 5% of patients who received BOT developed symptomatic, mild candida, which was easily treated with an oral antifungal agent. CONCLUSIONS In a randomized trial of adults with active EoE, we found that budesonide oral tablets were significantly more effective than placebo in inducing clinical and histologic remission. Eudra-CT number 2014-001485-99; ClinicalTrials.gov ID NCT02434029.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Spain.
| | - Stephan Miehlke
- Center for Digestive Diseases, Internal Medicine Center Eppendorf, Hamburg, Germany; Center for Esophageal Diseases, University Hospital Hamburg-Eppendorf, Germany
| | - Christoph Schlag
- II. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Michael Vieth
- Institute for Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Spain; Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Caceres, Spain
| | - Dirk Hartmann
- Klinik für Innere Medizin I, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Albert Jan Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Stefan Brückner
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus Technische Universität Dresden, Dresden, Germany
| | - Ahmed Madisch
- Department of Gastroenterology, CRH Clinic Siloah, Hannover, Germany
| | - Jamal Hayat
- Department of Gastroenterology, Saint George's University Hospitals National Health Service Trust, London, United Kingdom
| | - Jan Tack
- Department of Gastroenterology, University Hospital, Leuven, Belgium
| | - Stephen Attwood
- Department of Health Services Research, Durham University, Durham, United Kingdom
| | - Ralph Mueller
- Department of Clinical Research and Development, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Roland Greinwald
- Department of Clinical Research and Development, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Nelson MJ, Miller FH, Moy N, Zalewski A, Gonsalves N, Gregory DL, Hirano I. Comparison of endoscopy and radiographic imaging for detection of esophageal inflammation and remodeling in adults with eosinophilic esophagitis. Gastrointest Endosc 2018; 87:962-968. [PMID: 28989006 DOI: 10.1016/j.gie.2017.09.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/22/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Eosinophil predominant mucosal inflammation is central to the diagnosis and activity assessment of eosinophilic esophagitis (EoE). Esophageal mural remodeling is an important consequence of EoE that is responsible for adverse events of dysphagia, food impaction, and esophageal stenosis. The aim of this study was to compare upper endoscopy (EGD) with barium upper GI study (UGI) for the detection of esophageal inflammation and remodeling in adults with EoE. METHODS A retrospective review on a single-center database of adults with confirmed EoE identified those with EGD and UGI performed within 6 months of each another. Studies were reviewed for mucosal inflammatory and remodeling abnormalities. RESULTS Seventy patients were included. Initial UGI results were consistent with EoE in 10% and suggestive of EoE in 39%. Review of UGI by a senior GI radiologist increased detection of changes consistent with EoE (34%). EGD identified characteristic abnormalities in 93%, which was significantly greater than UGI (67%). Inflammatory features were more frequently appreciated on EGD (74%) compared with UGI (21%). There was no significant difference in fibrostenotic changes observed on EGD (84%) versus UGI (73%). CONCLUSIONS EGD and UGI have similar sensitivity for identifying the remodeling consequences of EoE; however, inflammatory features are better assessed on EGD. Inadequate sensitivity of UGI for composite features of EoE limits its capabilities as a diagnostic test, although radiologists' awareness significantly increases the diagnostic yield of UGI. UGI and EGD may identify fibrostenotic changes unappreciated by its counterpart and thus provide complementary information in select patients.
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Affiliation(s)
- Matthew J Nelson
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Frank H Miller
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nelson Moy
- Department of Gastroenterology, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Angelika Zalewski
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dyanna L Gregory
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Clayton F, Peterson K. Eosinophilic Esophagitis: Pathophysiology and Definition. Gastrointest Endosc Clin N Am 2018; 28:1-14. [PMID: 29129294 DOI: 10.1016/j.giec.2017.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Eosinophilic esophagitis is an adaptive immune response to patient-specific antigens, mostly foods. Eosinophilic esophagitis is not solely IgE-mediated and is likely characterized by Th2 lymphocytes with an impaired esophageal barrier function. The key cytokines and chemokines are thymic stromal lymphopoeitin, interleukin-13, CCL26/eotaxin-3, and transforming growth factor-β, all involved in eosinophil recruitment and remodeling. Chronic food dysphagia and food impactions, the feared late complications, are related in part to dense subepithelial fibrosis, likely induced by interleukin-13 and transforming growth factor-β.
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Affiliation(s)
- Frederic Clayton
- Department of Pathology, The University of Utah, Huntsman Cancer Hospital, 1950 Circle of Hope, Room N3100, Salt Lake City, UT 84112, USA
| | - Kathryn Peterson
- Division of Gastroenterology, The University of Utah, 30 North 1900 East SOM 4R118, Salt Lake City, UT 84132, USA.
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14
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Diagnosis and treatment of eosinophilic esophagitis in clinical practice. Clin J Gastroenterol 2017; 10:87-102. [DOI: 10.1007/s12328-017-0725-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/15/2017] [Indexed: 12/12/2022]
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