Combination Steroid and Test‐based Food Elimination for Eosinophilic Esophagitis

Abstract

Objectives: Eosinophilic esophagitis (EoE) is a clinicopathologic disorder characterized by infiltration of eosinophils into the esophagus. Primary treatment approaches include topical corticosteroids and/or food elimination. The aim of the present study was to compare the effectiveness of combination therapy (topical corticosteroid plus test-based food elimination [FS]) with single therapy (topical corticosteroid [S] or test-based food elimination [F]). Methods: Chart review of patients with EoE at Texas Children's Hospital (age <21 years) was performed. Clinical and histological statuses were evaluated after a 3-month treatment with either single or combination therapy. Comparisons were analyzed using Fisher exact test, Kruskal-Wallis tests, and multiple logistic regression models. Results: Among 670 charts, 63 patients (1-21 years, median 10.3 years) with clinicopathologic diagnoses of EoE were identified. Combination FS therapy was provided to 51% (n ¼ 32) and single treatment (S, F) to 27% (n ¼ 17) or 22% (n ¼ 14) of patients, respectively. Clinical responses were noted in 91% (n ¼ 29), 71% (n ¼ 12), and 64% (n ¼ 14) of patients in the FS, S, and F groups, respectively. The odds of clinically improving were 4.6 times greater (95% confidence interval: 1.1-18.8) with combination versus single therapy. The median peak number of eosinophils per high-power field after 3-month therapy was not significantly different in the S, F, and FS groups. Conclusions: The combination of topical corticosteroids with specific food elimination is as effective in achieving clinical and histological remissions as the single-treatment approaches. Responses were achieved with the combination in patients who had previously failed single-agent therapy. Prospective research of this combination approach in young patients with EoE is needed.

Medical and dietary management of eosinophilic esophagitis

“…Dual therapy with corticosteroid and elimination diet may be more effective in achieving clinical and histologic remission in some patients but has not been tested in a randomized, prospective manner. 76 In a retrospective study, combination therapy with topical corticosteroid, either swallowed aerosolized fluticasone or oral viscous budesonide, and TFED excluding only milk and soy for 3 months, followed by monotherapy with TFED only for 3 additional months, achieved clinical remission with reduction in dysphagia. 77 However, histologic remission after 3 months of combined dual therapy was lost after corticosteroid discontinuation.…”

Food avoidance strategies in eosinophilic oesophagitis

“…When possible, patients should be maintained on monotherapy to avoid risk of lack of compliance due to therapeutic complexity, add unnecessary cost and side‐effects . If monotherapy fails, a combination therapy with steroids and food avoidance or food avoidance and PPI is acceptable . Short courses of oral/systemic steroids or oesophageal dilations have also been used for short‐term control of the disease …”

Eosinophilic esophagitis in children: doubts and future perspectives

“…Studies showed that the combination of topical steroids with diet elimination is not superior to single treatment in achieving clinical or histological remission. However, combination therapy could be effective in patients who have previously failed single-agent therapy [54].…”