Food elimination diets are effective for long‐term treatment of adults with eosinophilic oesophagitis

Reed, Craig C.; Fan, Claire; Koutlas, Nathaniel T.; Shaheen, Nicholas J.; Dellon, Evan S.

doi:10.1111/apt.14290

Cited by 79 publications

(51 citation statements)

References 40 publications

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“…The effective therapies available to adults with EoE are numerous . We hypothesise that similar to other chronic conditions, knowledge of EoE patients’ expectations towards therapy in conjunction with, among others, adequate health literacy, and good physician‐patient partnership may lead to better decisions about the choice of therapy and reduce nonadherence .…”

Section: Discussionmentioning

confidence: 99%

Adults with eosinophilic oesophagitis identify symptoms and quality of life as the most important outcomes

Safroneeva

Balsiger

Hafner

et al. 2018

Aliment Pharmacol Ther

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Summary Background Well informed patients who are in cohesive partnership with physicians and who have realistic expectations towards therapy are more likely to be adherent, which results in better disease control. Aim To assess which therapy goals adults with eosinophilic oesophagitis consider relevant. Methods Following refinement during three focus groups, a study brochure and questionnaire were sent to 148 patients. Patients ranked the importance (five levels) of short‐term (in the next 3 months) and long‐term (≥1 year) treatment effect on symptoms, quality of life (QoL), histologically‐detected inflammation and fibrosis, endoscopically‐detected inflammation, and stricture formation as well as achieving histological remission while asymptomatic. Patients’ characteristics associated with treatment goals were identified using logistic regression. Results Of 109 respondents (mean age 43 years), 85 were men. Over 90% chose symptoms and QoL improvement as important short‐ and long‐term therapy goals. A greater proportion attributed more importance to long‐term reduction in endoscopic (90% vs 73%, P < 0.001) and histological (81% vs 62%, P = 0.002) inflammation, and histologically‐detected fibrosis (79% vs 64%, P = 0.018) when compared to short‐term reduction in these features. Patients (88%) ranked achieving histological remission while being asymptomatic as important. Gender, therapy use, education level, QoL, symptom severity, and history of dilation were associated with patients’ choice of treatment goals. Conclusions Patients attributed most importance to improvement in symptoms and QoL. Reduction in biological activity was judged less important, but more relevant in the long‐ compared to the short‐term.

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Section: Discussionmentioning

confidence: 99%

Adults with eosinophilic oesophagitis identify symptoms and quality of life as the most important outcomes

Safroneeva

Balsiger

Hafner

et al. 2018

Aliment Pharmacol Ther

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“…Among studies that examined the effectiveness of monoclonal antibody treatment in EoE subjects, 80% defined histological remission as peak esophageal eosinophil counts within the range of 0 to ≤5 24, 25, 26, 27, 28. Approximately 26% (N = 15) of the eligible studies examined remission among EoE patients who received only the diet elimination treatment formula (SFED, FFGED, ELED) compared to other forms of treatment, with the most common definitions falling within 0 to ≤5 eosinophils/hpf 29, 30, 31, 32, 33, 34 or 11 to ≤15 eosinophils/hpf 35, 36, 37, 38, 39, 40. Interestingly, even among the SFED studies (N = 9), five studies defined remission within the range of 0 to ≤5 eosinophils/hpf, 29, 30, 31, 32, 34 and two studies considered histological remission as <15 eosinophils/hpf 38, 41…”

Section: Resultsmentioning

confidence: 99%

“…diet elimination or restriction), we observed that medication trial studies (e.g. steroids, monoclonal antibody) used more rigorous criteria in their definition of histological remission in study subjects with EoE 21, 26, 27, 35, 53, 60. It is possible that different cut‐off values of peak eosinophil counts per hpf are appropriate for the definition of histological improvement because of the variations in the trial methodology (treatment, subjects’ characteristics).…”

Section: Discussionmentioning

confidence: 99%

Systematic review of histological remission criteria in eosinophilic esophagitis

Eke

White

et al. 2018

JGH Open

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Elemental diets, dietary elimination, and steroid therapies are the most common therapies in the clinical trials for eosinophilic esophagitis (EoE). Histological findings (usually reported as eosinophils per microscopic high‐powered field [hpf]) remain the most common end‐point used to define response. Yet, the threshold for defining “response” and “remission” are ill‐defined among consensus guidelines and may vary from study to study. We conducted a systematic literature review of articles on eosinophilic esophagitis, published between January 2007 and November 2017, considering histological remission as the primary outcome. We abstracted treatment information and definitions of histological remission or response. A comparison of definitions of histological remission across and within institutions was performed. A total of 61 articles were included in this review, with approximately 60% of the studies published from centers in the United States. Histological definitions of remission of EoE ranged from 0 to ≤20 eosinophils/hpf. The most stringent criteria, ranging from 0 to ≤5 eosinophils/hpf, were commonly used in interventional trial studies that examined the effects of new treatments. We found remarkable variability in definitions between studies, treatment types, and regions. Age or epidemiological distribution of study subjects did not influence the criteria for histological remission. Clinical and histological improvements are important measures of the effects of treatment. Histological findings, the most objective measure of treatment, should provide an optimal method for comparing the effectiveness of various treatments. Yet, our findings suggest a lack of consistent remission criteria in published studies. Considering these inconsistencies, it is difficult to compare the effectiveness of various treatments.

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“…9 As more patients are being treated with dietary intervention, further evidence regarding long-term outcomes is awaited. One recent study found that in patients who were able to adhere, dietary elimination remained effective, but over half of patients relapsed due to compliance or iatrogenic food reintroduction.…”

Section: Discussionmentioning

confidence: 99%

Multidisciplinary approach to the management of adult eosinophilic oesophagitis in the United Kingdom

Hunter

Pupinyte

Wong

et al. 2018

Clin Experimental Allergy

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Dietary intervention is effective for the management of eosinophilic oesophagitis (EoE) in both adults and children. 1 The majority of research has been conducted in Spain or the United States, 1 with no studies of dietary intervention published in the United Kingdom. Restrictive elimination diets can be challenging and swallowed topical corticosteroids have also been shown to be an effective treatment in adults. 2 Despite their efficacy, disadvantages include risk of candidiasis, 3 potential long-term effects such as adrenal suppression 3 and off-label medication use. Proton pump inhibitors (PPIs) are effective for a proportion of patients 4 although with both PPIs and corticosteroids, the underlying triggers of this presumed antigen-mediated condition are not identified and continued use is required to maintain efficacy. 3 A key aspect in the management of any allergic disease is avoidance of relevant allergens. Through a multidisciplinary collaboration between Adult Allergy, Gastroenterology, and Dietetics, we launched a service to provide dietary intervention for adults with EoE in a UK tertiary referral centre. We recently undertook a retrospective evaluation with the aim to describe the clinical phenotype of EoE in our service and to determine the clinico-pathological response to dietary or medical interventions in this cohort (GSTT service evaluation 6195). | ME TH ODSA search of the histology reporting system was performed in patients who had oesophageal biopsies taken over 2 years using the term "eosinophil". Patients were also identified by reviewing clinical records. The resulting list was manually screened for eligible patients, namely adults (>16 years) with an oesophageal eosinophil count over 15 per high power field (hpf) and documented history of suggestive symptoms.In our pathway (Figure 1), all patients with oesophageal eosinophilia were advised to start a PPI as per previous guidelines. 5 Both responsive and non-responsive patients were offered a choice between dietary management, corticosteroids or long-term PPI if responsive. Prior to dietary intervention, patients were assessed by both an Allergist and specialist allergy dietitian. They underwent extensive allergy testing using skin prick and serum specific IgE tests and were placed on a test-directed exclusion diet if any results were positive (unless solely sensitised to tree nuts). If no target foods were identified through testing, patients were recommended to undergo the six-food elimination diet (SFED), followed by sequential food reintroduction to identify triggers. A further biopsy was taken after 6 weeks of intervention. If the SFED was not successful, steroids or an elemental diet was recommended.Eosinophil counts and histological response were compared in those who had both pre-and post-treatment endoscopies for PPIs, steroids, and dietary interventions. All were undertaken for a minimum of 6 weeks for diet and 8 weeks for PPI and corticosteroids.Complete histological response was defined as an eosinophil count of less than 5 cell...

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Food elimination diets are effective for long‐term treatment of adults with eosinophilic oesophagitis

Cited by 79 publications

References 40 publications

Adults with eosinophilic oesophagitis identify symptoms and quality of life as the most important outcomes

Adults with eosinophilic oesophagitis identify symptoms and quality of life as the most important outcomes

Systematic review of histological remission criteria in eosinophilic esophagitis

Multidisciplinary approach to the management of adult eosinophilic oesophagitis in the United Kingdom

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