Guidelines on eosinophilic esophagitis: evidence‐based statements and recommendations for diagnosis and management in children and adults

Abstract

Introduction: Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. This underlines the importance of optimizing diagnosys and treatment of the condition, especially after the increasing amount of knowledge on EoE recently published. Therefore, the UEG, EAACI ESPGHAN, and EUREOS deemed it necessary to update the current guidelines regarding conceptual and epidemiological aspects, diagnosis, and treatment of EoE. Methods: General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used in order to comply with current standards of evidence assessment in formulation of recommendations. An extensive literature search was conducted up to August 2015 and periodically updated. The working group consisted of gastroenterologists, allergists, pediatricians, otolaryngologists, pathologists, and epidemiologists. Systematic evidence-based reviews were performed based upon relevant clinical questions with respect to patient-important outcomes. Results: The guidelines include updated concept of EoE, evaluated information on disease epidemiology, risk factors, associated conditions, and natural history of EoE in children and adults. Diagnostic conditions and criteria, the yield of diagnostic and disease monitoring procedures, and evidence-based statements and recommendation on the utility of the several treatment options for patients EoE are provided. Recommendations on how to choose and implement treatment and long-term management are provided based on expert opinion and best clinical practice. Conclusion: Evidence-based recommendations for EoE diagnosis, treatment modalities, and patients' follow up are proposed in the guideline.

Eosinophilic Esophagitis: Treatment With Different Doses of Omeprazole in Children Under 16 Years

“…The response of EoE to PPIs has been well studied in adults and children [1,2]; however, depending on the studies consulted, remission may be less frequent in children than in adults [1,2,6].…”

“…Despite the lack of expert consensus on whether PPIs should be the first-line treatment in EoE [4,7], we began treatment with omeprazole because it is well-tolerated, has few adverse effects, and induces clinical and histological remission of the disease in up to half of patients [1,2]. In the children in the present study, remission was much lower after treatment with high-dose PPIs than in a previously published study, in which 68% of patients achieved remission after treatment with esomeprazole, with sustained remission in 78% after lowering the dose by half [8].…”

“…Some experts advise treating EoE with PPIs, as they are well tolerated and adverse effects are minimal. In addition, many patients respond to high doses of PPIs, with no significant differences in patient age, study design, or type of PPI assessed [1,2]. The objectives of our study were to calculate the proportion of patients with EoE who experienced clinical and histological remission with high doses of PPIs (≤40 kg, omeprazole at 1 mg/k/12 h for 2 months; >40 kg, omeprazole at 40 mg/12h for 2 months) in order to determine which patients with EoE responded to PPIs, assess the persistence of remission when the dose of omeprazole is reduced by half, and evaluate possible adverse effects of omeprazole during the first 6 months of therapy.…”

“…We studied the proportion of patients who responded to 1 mg/k/d of omeprazole, which was administered in 2 doses in children weighing ≤40 kg; in patients weighing more than 40 kg, the prescribed dose was 80 mg/d, for at least 2 months. Nonresponse to treatment with PPIs was defined as at least 15 eos/hpf [1,2]. During the first 6 months of treatment with omeprazole, patients were reviewed every 2 months and asked about possible adverse effects of omeprazole.…”

Biomarkers and therapeutic targets: microRNA roles in the pathophysiology, diagnosis and management of eosinophilic esophagitis

“…EoE is characterized by eosinophil-rich gastrointestinal inflammation in the absence of other underlying causes of eosinophilia such as parasitic infection, inflammatory bowel disease, celiac disease, drug hypersensitivity, malignancy, graft-vs-host disease, connective tissues disease and autoimmune disorders [7,8] . Although the etiology of EoE is still under active investigation, aeroallergen and food antigen exposure are known to trigger inflammation [9][10][11] . In fact, an allergic origin for EoE is supported by a close association with comorbid atopic diseases such as eczema, food allergy, asthma and allergic rhinitis [12] .…”