1
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Njie C, Richman C, Rebhun J, Achalu S, Kamal AN, Otaki F, Leiman DA, Kathpalia P. Identification of gaps in the delivery of high-quality care of patients with eosinophilic esophagitis. Dis Esophagus 2024:doae055. [PMID: 39007698 DOI: 10.1093/dote/doae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/12/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024]
Abstract
Quality indicators (QIs) are standardized metrics that can be used to quantify health care delivery and identify important areas for practice improvement. Nine QIs pertaining to the diagnosis and management of eosinophilic esophagitis (EoE) were recently established. We therefore aimed to identify existing gaps in care using these QIs. This is a retrospective, multicenter study utilizing recently established EoE QIs to evaluate practice patterns among adult gastroenterologists in the diagnosis and management of EoE. Three patient cohorts of 30 patients each presenting with dysphagia, food impaction, and new diagnosis of EoE, respectively, were obtained, yielding 120 patients per site to assess for every QI. Summary statistics were reported across two main themes: diagnosis and management. Subsequent analysis of gaps in care was then performed. The domain of diagnosis of EoE (QI 1 and 2) had the most notable gap in care with only 55% of the presenting patients undergoing appropriate evaluation for EoE. The domain of management of EoE had overall higher QI fulfillment-however it also contained significant intra-category variation in care. Notably, while 79% of patients had clinical follow-up within 1 year from remission, only 54% underwent surveillance endoscopy within 2 years of remission. In contrast, 100% of patients with symptomatic strictures independent of histologic response underwent endoscopic dilation (QI 4). Management approaches for EoE are evolving and variation in care delivery exists. We identified significant gaps in both diagnosis of EoE especially amongst patients presenting with index food impaction and long term management of EoE, when retrospectively evaluating care patterns using newly established QIs. This is the first study of its kind to utilize these previously established QIs to objectively identify care gaps that exist in EoE amongst several institutions. These findings also highlight the importance of QIs and standardization of management of complex chronic diseases like EoE to help bridge these gaps and provide a framework to measure adherence to these best practices.
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Affiliation(s)
- Cheikh Njie
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | - Afrin N Kamal
- Department of Medicine, Stanford University, Stanford, CA, USA
- Division of Gastroenterology and Hepatology, Stanford University, CA, USA
| | - Fouad Otaki
- Division of Gastroenterology, OHSU, Portland, OR, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Priya Kathpalia
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
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2
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Reddy AT, Lee JP, Leiman DA. Measuring and improving quality in esophageal care and swallowing disorders. Dis Esophagus 2024; 37:doae013. [PMID: 38458618 DOI: 10.1093/dote/doae013] [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: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024]
Abstract
Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.
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Affiliation(s)
| | - Joshua P Lee
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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3
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology 2022; 163:59-76. [PMID: 35606197 PMCID: PMC9233087 DOI: 10.1053/j.gastro.2022.03.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Bob Geng
- University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven, Connecticut; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden, Connecticut
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children, Indianapolis, Indiana; Community Health Network, Indianapolis, Indiana
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy, Immunology, University of California-San Diego, San Diego, California
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4
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. J Allergy Clin Immunol 2022; 150:33-47. [PMID: 35606166 PMCID: PMC9549868 DOI: 10.1016/j.jaci.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora; Children's Hospital Colorado, Aurora
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati; Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora; Digestive Health Institute, Children's Hospital Colorado, Aurora
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam
| | - Bob Geng
- University of California San Diego, San Diego; Rady Children's Hospital, San Diego
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock; Arkansas Children's Hospital, Little Rock
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis; Riley Hospital for Children, Indianapolis; Community Health Network, Indianapolis
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid; Instituto de Investigación Sanitaria La Princesa, Madrid
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville
| | | | | | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora
| | - Seema S Aceves
- Rady Children's Hospital, San Diego; Division of Allergy, Immunology, University of California-San Diego, San Diego
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5
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Chehade M, Falk GW, Aceves S, Lee JK, Mehta V, Leung J, Shumel B, Jacob-Nara JA, Deniz Y, Rowe PJ, Cunoosamy D, Khodzhayev A. Examining the Role of Type 2 Inflammation in Eosinophilic Esophagitis. GASTRO HEP ADVANCES 2022; 1:720-732. [PMID: 39131849 PMCID: PMC11307682 DOI: 10.1016/j.gastha.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/06/2022] [Indexed: 08/13/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2 inflammatory disease characterized by an eosinophilic inflammatory infiltrate in the esophagus, leading to remodeling, stricture formation, and fibrosis. Triggered by food and aeroallergens, type 2 cytokines interleukin (IL)-4, IL-13, IL-5 produced by CD4+ T helper 2 cells (Th2), eosinophils, mast cells, basophils, and type 2 innate lymphoid cells alter the esophageal epithelial barrier and increase inflammatory cell tissue infiltration. Clustering analysis based on the expression of type 2 inflammatory genes demonstrated the diversity of EoE endotypes. Despite the availability of treatment options for patients with EoE, which include dietary restriction, proton pump inhibitors, swallowed topical steroids, and esophageal dilation, there are still no Food and Drug Administration-approved medications for this disease; as such, there are clear unmet medical needs for these patients. A number of novel biologic therapies currently in clinical trials represent a promising avenue for targeted therapeutic approaches in EoE. This review summarizes our current knowledge on the role of type 2 inflammatory cells and mediators in EoE disease pathogenesis, as well as the future treatment landscape targeting underlying inflammation in EoE.
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Affiliation(s)
- Mirna Chehade
- Deparment of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gary W. Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Seema Aceves
- Deparment of Pediatrics and Medicine, University of California, San Diego, California
| | - Jason K. Lee
- Deparment of Clinical Immunology and Allergy and Internal Medicine, Toronto Allergy and Asthma Clinic, Toronto, Ontario, Canada
| | - Vinay Mehta
- Allergy, Asthma & Immunology Associates, P.C., Lincoln, Nebraska
| | - John Leung
- Boston Specialists, Boston, Massachusetts
| | - Brad Shumel
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
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6
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Navarro P, Laserna-Mendieta EJ, Casabona S, Savarino E, Pérez-Fernández MT, Ghisa M, Pérez-Martínez I, Guagnozzi D, Perelló A, Guardiola-Arévalo A, Racca F, Betoré E, Blas-Jhon L, Krarup AL, Martín-Domínguez V, Maniero D, Suárez A, Llerena-Castro R, de la Peña-Negro L, Navacerrada AG, Pellegatta G, Alcedo J, de Hurtado Mendoza-Guena L, Feo-Ortega S, Barrio J, Gutiérrez-Junquera C, Fernández-Fernández S, De la Riva S, E Navés J, Carrión S, Ciriza de Los Ríos C, García-Morales N, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Palomeque MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J 2022; 10:507-517. [PMID: 35578565 PMCID: PMC9189464 DOI: 10.1002/ueg2.12240] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. Objective To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Methods Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Results Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). Conclusion The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Viladecans, Spain
| | | | - Francesca Racca
- Personalized Medicine, Asthma and Allergy. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Adolfo Suárez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Gaia Pellegatta
- Endoscopy Unit. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Javier Alcedo
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Sara Feo-Ortega
- Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Navés
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | - Constanza Ciriza de Los Ríos
- Department of Gastroenterology. Hospital Clínico Universitario San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Madrid, Spain.,Universidad Complutense, Madrid, Spain
| | | | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaela Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | | | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
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7
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Tamarit-Sebastian S, Ferrer-Soler FM, Lucendo AJ. Current options and investigational drugs for the treatment of eosinophilic esophagitis. Expert Opin Investig Drugs 2022; 31:193-210. [DOI: 10.1080/13543784.2022.2033207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sonsoles Tamarit-Sebastian
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
| | - Francisco Miguel Ferrer-Soler
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria Princesa (IIS-IP)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
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8
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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9
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Improving Delivery of Care through Standardized Monitoring in Children with Eosinophilic Esophagitis. Pediatr Qual Saf 2021; 6:e429. [PMID: 34345747 PMCID: PMC8322550 DOI: 10.1097/pq9.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/04/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Eosinophilic esophagitis (EoE) is a chronic, antigen-driven disorder for which endoscopic monitoring and multidisciplinary care are recommended to achieve histologic remission. The EoE team at our large academic center developed a quality improvement (QI) initiative aimed to reduce variability in monitoring. This QI project focused on completing 3 process metrics within 6 months of diagnosis: (1) outpatient follow-up with a gastroenterologist; (2) referral to an allergist; and (3) Follow-up esophagogastroduodenoscopy (EGD). Methods: In January 2015, our QI team developed a registry of newly diagnosed EoE patients and maintained ongoing, weekly tracking of the process measures. Interventions to increase the completion of the process metrics included educational sessions, proactive reminders to providers, and targeted communications with patient families. Missed opportunities were evaluated by more in-depth chart review and categorized as provider- or patient-driven. Results: We tracked 6-month process metrics from 2015 through 2018. During this interval, follow-up visit rates in GI improved from 77% to 86%, and the percentage of referrals placed to allergy increased from 65% to 77%. The percentage of patients completing a repeat EGD improved from 33% to 61%. Among patients without a repeated EGD, nearly 70% of those missed opportunities were provider-driven. Conclusions: In patients newly diagnosed with EoE, QI interventions, including patient registry development, implementation of a local standard of care, and creating a patient tracking system, improved adherence with national EoE monitoring guidelines.
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Sharma A, Eluri S, Philpott H, Lemberg DA, Dellon ES. EoE Down Under Is Still EoE: Variability in Provider Practice Patterns in Australia and New Zealand Among Pediatric Gastroenterologists. Dig Dis Sci 2021; 66:2301-2310. [PMID: 32816214 DOI: 10.1007/s10620-020-06534-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is likely variation in approach and management of patient with EoE due to lack of standardized care and variation in guidelines. We aimed to identify current practices regarding diagnosis and treatment in children with eosinophillic esophagitis (EoE) in Australia and New Zealand (ANZ). METHODS Information on current diagnostic and management approaches for pediatric EoE was collected via an online survey sent to pediatric gastroenterologists (pGE) in ANZ. We performed a cross-sectional study of pGE using a 49-question instrument regarding evaluation, diagnostic, and therapeutic aspects of EoE between October 2019 and December 2019. RESULTS Eighty-five percent of the survey responders were from Australia, and 66% were academic. 30% pGE perform > 3 esophageal biopsies for diagnosis of EoE, 40% involve an allergist, 30% use a twice daily PPI trial, and 70% do not exclude other cause of esophageal eosinophilia. For management, only 3% use dietary elimination as an initial therapy, and 24% use less than the recommended doses of swallowed fluticasone. Forty-nine percent were likely to stop treatment in after remission is achieved for 12 months. The EoE endoscopic reference score (EREFS) was not routinely used (49%). Two-thirds of pGE are concerned about long-term effects of recurrent need of general anesthesia. CONCLUSIONS Diagnostic and management strategies for EoE differed widely among pGE in ANZ, including in diagnostic biopsies, assessing competing causes of esophageal eosinophilia, initials selection of treatments, and maintenance strategies. This variability likely reflects continued uncertainty regarding optimal management strategies and stresses the need for pediatric-specific ANZ guidelines to standardize EoE care.
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Affiliation(s)
- Ajay Sharma
- Department of Paediatrics, St John of God Hospital, Midland, Perth, Australia. .,Curtin Medical School, Curtin University, Perth, WA, Australia. .,Perth Paediatrics, 5/2 McCourt Street, West Leederville, Perth, WA, Australia.
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
| | - Hamish Philpott
- Northern Adelaide Local Health Network, Department of Gastroenterology, University of Adelaide, Adelaide, SA, Australia
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital and School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
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11
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Chang JW, Rubenstein JH, Mellinger JL, Kodroff E, Strobel MJ, Scott M, Mack D, Book W, Sable K, Kyle S, Paliana A, Dellon ES. Motivations, Barriers, and Outcomes of Patient-Reported Shared Decision Making in Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:1808-1817. [PMID: 32621259 PMCID: PMC9110111 DOI: 10.1007/s10620-020-06438-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about patient choice in treatment of eosinophilic esophagitis (EoE). AIM Determine motivators and barriers to using common EoE therapies and describe patient-reported shared decision making (SDM) and satisfaction with treatment. METHODS We developed and administered a Web-based survey on factors influencing EoE treatment choice, SDM, and satisfaction. Adults with EoE and adult caregivers of pediatric EoE patients were recruited via patient advocacy groups and at two centers. Descriptive statistics of multiple response questions and multivariable logistic regression were performed to identify predictors of SDM and satisfaction with treatment. RESULTS A total of 243 adults (mean age 38.7 years) and 270 adult caregivers of children (mean age 9.5 years) completed the survey. Preventing worsening disease was the most common motivator to treat EoE. Barriers to topical steroids were potential side effects, cost, and preferring a medication-free approach. Inconvenience and quality of life were barriers to diet. Potential adverse events, discomfort, and cost were barriers to dilation. Nearly half (42%) of patients experienced low SDM, but those followed by gastroenterologists were more likely to experience greater SDM compared to non-specialists (OR 1.81; 95% CI 1.03-3.15). Patients receiving more SDM were more satisfied with treatment, regardless of provider or treatment type (OR 2.62, 95% CI 1.76-3.92). CONCLUSIONS Patients with EoE pursue treatment mostly to prevent worsening disease. Common barriers to treatment are inconvenience and financial costs. SDM is practiced most by gastroenterologists, but nearly half of patients do not experience SDM, indicating a substantial area of need in EoE.
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Affiliation(s)
- Joy W. Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Joel H. Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA,Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Jessica L. Mellinger
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Mary J. Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | | | - Denise Mack
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Wendy Book
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Kathleen Sable
- American Partnership for Eosinophilic Disorders, Atlanta, GA, USA
| | - Scholeigh Kyle
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Allisa Paliana
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, IL, USA
| | - Evan S. Dellon
- Division of Gastroenterology, Center for Esophageal and Swallowing Disorders, University of North Carolina, Chapel‑Hill, NC, USA
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12
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Kim SJ, Park MI, Kim GH, Lee MW, Jung K, Lee J, Seol SY, Jee SR, Lee HS, Jang JS, Cha JH. Practice Patterns for Eosinophilic Esophagitis Patients in Busan and Gyeongnam: A Korean Multicenter Database Study. J Neurogastroenterol Motil 2021; 27:71-77. [PMID: 32699187 PMCID: PMC7786091 DOI: 10.5056/jnm20069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Background/Aims The prevalence of eosinophilic esophagitis is increasing in Korea and there are few single-center studies regarding eosinophilic esophagitis in Korea. In particular, data about management for eosinophilic esophagitis are lacking. We aim to evaluate the practice patterns, including initial treatment and response, in the Busan city and Gyeongnam province area. Methods We retrospectively reviewed medical records to gain data on patient characteristics, medication, endoscopic images, and esophageal biopsy results. From January 2009 to December 2019, a total of 42 patients were diagnosed with eosinophilic esophagitis. Results The mean age was 50.7 (from 22 to 81) years and the cohort was predominantly male (78.6%, 33/42). The proton pump inhibitor was the preferred treatment as an initial trial for 64.3% (27/42) of patients, followed by swallowed topical steroids (16.7%, 7/42). Clinical improvement after proton pump inhibitor therapy was achieved in 88.9% (24/27) of patients. Two patients who did not achieve improvement showed a clinical and endoscopic response after swallowed topical steroids treatment. No patient received diet elimination or balloon dilatation therapy. Conclusions The treatment response of eosinophilic esophagitis was good in Busan city and Gyeongnam province area in Korea. Proton pump inhibitor therapy was the preferred and most effective treatment for eosinophilic esophagitis as the initial therapy.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jin Lee
- Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
| | - Sang Young Seol
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Sam Ryong Jee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Jin Seok Jang
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jae Hwang Cha
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
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13
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Jensen ET, Langefeld CD, Zimmerman KD, Howard TD, Dellon ES. Epigenetic methylation in Eosinophilic Esophagitis: Molecular ageing and novel biomarkers for treatment response. Clin Exp Allergy 2020; 50:1372-1380. [PMID: 32986922 DOI: 10.1111/cea.13748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Treatment failure in eosinophilic esophagitis (EoE) is common. We hypothesize that DNA methylation differs between patients by treatment response to topical steroids (oral viscous budesonide), thus offering the potential to inform targeting therapies. OBJECTIVE We sought to identify differentially methylated sites and affiliated genes in pre-treatment oesophageal cells between responders and non-responders and test for accelerated epigenetic ageing in oesophageal cells of EoE patients. METHODS DNA was extracted from prospectively collected and biobanked oesophageal biopsies from 36 Caucasian treatment naïve EoE patients at diagnosis. Methylation assays were completed using the Infinium HumanMethylation450 BeadChip. Normalized β values for each CpG site were tested (t test) for differential methylation. Further, 353 CpG probes were used to estimate epigenetic age for each patient and a linear regression model tested whether chronologic age and epigenetic age differed. Epigenetic age results were confirmed in an independent cohort of healthy controls. RESULTS Eighteen CpG sites were differentially methylated by treatment response (P < .00001). The mean epigenetic age and chronological age were 56.1 ± 11.1 and 36.7 ± 12.3 years, a mean age difference of 19.3 ± 5.2 years (P < .0001); accelerated ageing was not observed in the oesophageal cells of healthy controls. CONCLUSIONS AND CLINICAL RELEVANCE EoE patients that respond versus do not respond to treatment have differences in their methylation profile, including enrichment of genes in pathways consistent with cellular injury and repair due to environmental stress and cell adhesion and barrier integrity. EoE also appears to accelerate cellular ageing. Whether treatment can arrest or reverse accelerated epigenetic ageing and the implications for long-term disease progression is important areas for future research.
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Affiliation(s)
- Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Internal Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carl D Langefeld
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kip D Zimmerman
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy D Howard
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Laserna-Mendieta EJ, Casabona S, Savarino E, Perelló A, Pérez-Martínez I, Guagnozzi D, Barrio J, Guardiola A, Asensio T, de la Riva S, Ruiz-Ponce M, Rodríguez-Oballe JA, Santander C, Arias Á, Lucendo AJ. Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice. Clin Gastroenterol Hepatol 2020; 18:2903-2911.e4. [PMID: 31988045 DOI: 10.1016/j.cgh.2020.01.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/07/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Topical steroids, proton pump inhibitors (PPIs), and dietary interventions are recommended first- and second-line therapies for eosinophilic esophagitis (EoE). We investigated differences in their effectiveness in a real-world, clinical practice cohort of patients with EoE. METHODS We collected data on the efficacy of different therapies for EoE (ability to induce clinical and histologic remission) from the multicenter EoE CONNECT database-a database of patients with a confirmed diagnosis of EoE in Europe that began in 2016. We obtained data from 589 patients, treated at 11 centers, on sex, age, time of diagnosis, starting date of any therapy, response to therapy, treatment end dates, alternative treatments, and findings from endoscopy. The baseline endoscopy was used for diagnosis of EoE; second endoscopy was performed to evaluate response to first-line therapies. After changes in treatment, generally because lack of efficacy, a last endoscopy was performed. The time elapsed between endoscopies depended on the criteria of attending physicians. Clinical remission was defined by a decrease of more than 50% in Dysphagia Symptom Score; improvement in symptoms by less than 50% from baseline was considered as clinical response. Histologic remission was defined as a peak eosinophil count below 5 eosinophils/hpf. A peak eosinophil count between 5 and 14 eosinophils/hpf was considered histologic response. We identified factors associated with therapy selection and effectiveness using χ2 and multinomial logistic regression analyses RESULTS: PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%). Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%). Among the 344 patients who switched to a second-line therapy, dietary interventions were selected for 47.1% of patients, followed by PPIs (for 29.1%) and topical steroids (for 18.6%). Clinical and histologic remission or response was achieved by 80.7% of patients treated with topical steroids, 69.2% of patients given PPIs, and 41.7% of patients on empiric elimination diets. Multivariate analyses found the stricturing phenotype of EoE to be associated with selection of topical steroids over PPIs as the first-line therapy; lack of fibrotic features at initial endoscopy was associated with selection of elimination diets over topical steroids as a second-line therapy. The recruiting center was significantly associated with therapy choice; second-line treatment with topical steroids or PPIs were the only variables associated with clinical and histologic remission. CONCLUSIONS In an analysis of data from a large cohort of patients with EoE in Europe, we found topical steroids to be the most effective at inducing clinical and histologic remission, but PPIs to be the most frequently prescribed. Treatment approaches vary with institution and presence of fibrosis or strictures.
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Affiliation(s)
- Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain.
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Villadecans, Barcelona, Spain
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Antonio Guardiola
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria La Paz, Madrid, Spain
| | - Teresa Asensio
- Department of Allergy, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Miriam Ruiz-Ponce
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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15
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Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. J Pediatr Gastroenterol Nutr 2020; 71:83-90. [PMID: 32097371 DOI: 10.1097/mpg.0000000000002672] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. METHODS A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). RESULTS Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow-up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton-pump inhibitors (PPIs), topical steroids were the preferred second-line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first-line therapy, in contrast to most other countries. CONCLUSIONS Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.
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Eluri S, Iglesia EGA, Massaro M, Peery AF, Shaheen NJ, Dellon ES. Practice patterns and adherence to clinical guidelines for diagnosis and management of eosinophilic esophagitis among gastroenterologists. Dis Esophagus 2020; 33:doaa025. [PMID: 32378700 PMCID: PMC7350163 DOI: 10.1093/dote/doaa025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
Real-world practice patterns of eosinophilic esophagitis (EoE) among gastroenterologists are not well-described. The aim is to describe practice patterns of EoE diagnosis and management and assess concordance with consensus guidelines. We conducted a cross-sectional online survey of gastroenterologists in the USA using Qualtrics, which was dispersed through the North Carolina Society of Gastroenterology (NCSG) and the American College of Gastroenterology member listservs. A similar survey was sent to NCSG members in 2010 and responses were compared in a subanalysis. Of 240 respondents, 37% (n = 80) worked in an academic setting versus 63% (n = 138) community practice setting. Providers saw a median of 18 (interquartile range 2-100) EoE patients annually and 24% (n = 52) were 'very familiar' with EoE guidelines. A proton-pump inhibitor (PPI) trial was required by 37% of providers prior to EoE diagnosis. In total, 60% used a ≥15 eosinophils per high-power field cut point for diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n = 28) followed EoE diagnosis guidelines. For first-line treatment, 7% used dietary therapy, 32% topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. In the NCSG cohort, a higher proportion in 2017 followed guideline diagnosis recommendations compared with 2010 (14% vs. 3%; P = 0.03) and a higher proportion used dietary therapy as first-line treatment (13% vs. 3%; P = 0.046). There is variability in EoE practice patterns for EoE management, with management differing markedly from consensus guidelines. Further education and guideline dissemination are needed to standardize practice.
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Affiliation(s)
- Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Edward G A Iglesia
- Division of Pediatric Allergy, Immunology, and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Massaro
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Anne F Peery
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Engaging patient partners in state-of-the-art allergy care: Finding balance when discussing risk. Ann Allergy Asthma Immunol 2020; 125:252-261. [PMID: 32044453 DOI: 10.1016/j.anai.2020.01.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/03/2020] [Accepted: 01/22/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To review risk communication in the context of shared decision making. DATA SOURCES Articles describing risk communication, shared decision making, and cost-effective healthcare delivery. STUDY SELECTIONS A narrative review detailing approaches to improve risk communication and shared decision making to optimize patient-centered cost-effective practice. RESULTS Risk communication must occur on a foundation of mutual trust and can be improved by keeping risk in perspective of everyday hazards, such as using pictograms when possible, providing numeric likelihoods of risks and benefits, and discussing absolute risks. Variability in patient-perceived quality of life for allergic and nonallergic health states may affect the health and economic outcomes of many allergy therapies. Shared decision making improves patient knowledge and risk perception, engagement, and adherence. Patient decision aids can be time-consuming to develop and validate, but their use is associated with a more accurate understanding of patient-oriented outcomes. CONCLUSION Communicating risk is complex, and validated patient decision aids using visual aids, presenting essential information, using knowledge checks, and incorporating values clarification can reduce decisional conflict and improve decisional self-efficacy.
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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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19
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Avoidant/Restrictive Food Intake Disorder in Diet-treated Children With Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2019; 69:57-60. [PMID: 30889128 DOI: 10.1097/mpg.0000000000002323] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is an inflammatory condition of the esophagus with rising incidence in children. Owed to potential adverse effects and high costs of EoE medications, strict elimination diets are often employed as a mainstay of long-term EoE therapy in children. Currently, there are no effective tests to pinpoint food protein triggers in children with EoE. Therefore, EoE elimination diets are often broad (including milk, soy, wheat, egg, fish/shellfish, and nuts) and can greatly alter a child's baseline eating habits. Herein, we describe 2 cases of avoidant/restrictive food intake disorder (ARFID) in children with remitted EoE maintained on an elimination diet. We also present comorbidity data on ARFID and diet-treated EoE from our pediatric EoE clinic. This is the first report of disordered eating associated with EoE therapy. As EoE is becoming more common, close monitoring of intake and growth in patients treated with elimination diets will be key.
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20
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Jensen ET, Huang KZ, Chen HX, Landes LE, McConnell KA, Almond MA, Safta A, Johnston DT, Durban R, Jobe L, Frost C, Donnelly S, Antonio B, Quiros JA, Markowitz JE, Dellon ES. Longitudinal Growth Outcomes Following First-line Treatment for Pediatric Patients With Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2019; 68:50-55. [PMID: 30074576 PMCID: PMC6449848 DOI: 10.1097/mpg.0000000000002114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES No formal comparative effectiveness studies have been conducted to evaluate the effect of eosinophilic esophagitis (EoE) treatment choice on long-term growth in pediatric patients. Long-term studies of inhaled corticoid steroids in asthma, however, suggest possible effects on linear growth. The aim of this study was to compare longitudinal, anthropometric growth in children with EoE according to treatment approach. METHODS We conducted a retrospective, multicenter cohort study of anthropometric growth (height and body mass index [BMI] z scores) in pediatric (<18 years of age) patients newly diagnosed with EoE across 5 clinical sites between 2005 and 2014. We compared differences in growth according to treatment approach over a 12-month period. Modification by sex and age was examined and sensitivity analyses were conducted to assess robustness of results given study assumptions. RESULTS In the 409 patients identified, the mean age and proportion male differed by treatment (P = < 0.01 and P = 0.04, respectively). Baseline growth measures were associated with slight impairment of height at diagnosis (median baseline height z score of -0.1 [interquartile range -0.9, 0.8]). In general, treatment approach was not associated with any significant increase or decrease in expected growth over a 12-month period. Subtle decrease in linear growth was observed with treatment using a combined elemental and topical steroid (Δ height z score [adjusted]: -0.04; 95% confidence interval [CI]: -0.08, -0.01). Differences in linear growth differed by sex (P for interaction <0.01). For elemental formula in combination with topical steroids, only girls exhibited a significant decline in linear growth (Δ height z score [adjusted]: -0.24; 95% CI: -0.32, -0.17). A slight reduction in BMI was observed for patients treated with a combination of elemental diet and dietary elimination (Δ BMI z score [adjusted]: -0.07; 95% CI: -0.13, -0.01). CONCLUSIONS Treatment of EoE, in general, is not associated with major anthropometric growth changes in most pediatric patients. Slight linear growth impairment was observed for topical steroid treatment, and sex differences in growth by treatment approach were observed. Future prospective studies should evaluate the effect of treatment on optimal growth and development and over a longer period of follow-up.
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Affiliation(s)
- Elizabeth T. Jensen
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kevin Z. Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Hannah X. Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lisa Englander Landes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Kristen A McConnell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - M. Angie Almond
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Anca Safta
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | - Laura Jobe
- University of South Carolina School of Medicine, Greenville, SC
- Greenvile Children’s Hospital; Greenville, SC
| | | | - Sarah Donnelly
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - Brady Antonio
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - J. Antonio Quiros
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - Jonathan E. Markowitz
- University of South Carolina School of Medicine, Greenville, SC
- Greenvile Children’s Hospital; Greenville, SC
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
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