Curr Gastroenterol Rep (2014) 16:364 DOI 10.1007/s11894-013-0364-y
ESOPHAGUS (L GERSON, SECTION EDITOR)
Which Patients with Eosinophilic Esophagitis (EoE) Should Receive Elemental Diets Versus Other Therapies? Kathryn A. Peterson & Kathleen K. Boynton
Published online: 15 December 2013 # Springer Science+Business Media New York 2013
Abstract Eosinophilic esophagitis (EoE) has increasingly been identified in both children and adults. The aim of therapies is to alleviate symptoms while reducing the esophageal inflammation. Mechanical dilation is effective at relieving symptoms, but without the benefit of controlling disease inflammation. Topical steroids appear to be effective at controlling both symptoms and esophageal eosinophilia. Recurrence rates are high once steroids are discontinued. For dietary modification, both the elimination of select, specific foods and the complete elimination of food proteins via amino acid formulas have been looked at. Both forms of dietary modification are effective. Elemental diet, although not an ideal firstline therapy for EoE, provides insight into the etiology of unusual or refractory EoE. The contribution of unusual food antigens to EoE may be determined via the use of amino-acidbased formulas in patients with EoE. Keywords Eosinophilic esophagitis . Esophageal dilation . Topical steroids . Elimination diet . Elemental diet
Introduction Eosinophilic esophagitis (EoE) is characterized by an immune response manifested as eosinophilic inflammation in the esophagus [1–3]. When left uncontrolled over time, the inflammation, involving mast cells (mediators of TGF beta and additional remodeling proteins) as well as eosinophils, results in esophageal strictures, spasms, and subsequent food
impactions [4]. Current therapies focus on alleviating symptoms while reducing histologic inflammation. Various therapies have been attempted to control the inflammation in order to reduce the complications and symptoms of the disease [5]. Treatments studied have focused on mechanical dilation of strictures, altering the effects of specific proteins involved in the pathogenesis of esophageal eosinophilia (biologics), dampening the immune response to such signals (topical steroids), or removing the offending agent that is triggering the reaction (elemental or food elimination diets). The goals of therapy include the following: relief of symptoms, reduction in inflammation, and prevention of strictures and associated complications without causing nutritional compromise. The ACG guidelines for 2013 recommended both steroids (topical) and dietary therapy as effective first-line treatments for EoE and suggested that dietary therapy be tailored to patient needs and available resources [3]. Gastroenterologists should consider both patient preference and efficacy as they decide upon treatment. Biologics are expensive and not currently FDA approved. Optimal dosages for topical steroids have been incompletely characterized, and complications of candidiasis have been reported. Food elimination diets are effective, but compliance is difficult to confirm (especially since the primary patients with EoE are young males who are notorious for compliance issues). Elemental diets (ELEDs) are effective but plagued with concerns over compliance. Below, we will review the most common clinically available therapies for adult EoE and suggest a role for ELED in the therapeutic realm.
This article is part of the Topical Collection on Esophagus K. A. Peterson (*) : K. K. Boynton Division of Gastroenterology, University of Utah, 30 North 1900 East SOM4R118, Salt Lake City, UT 84132, USA e-mail: [email protected]
Dilation Similar to inflammatory bowel disease, chronic, uncontrolled inflammation leads to fixed, fibrotic strictures in EoE over
364, Page 2 of 7
time [4]. In such patients, resolution of dysphagia cannot be completely achieved without undergoing mechanical dilation [5]. Dilation may occur as needed in patients and offers patients a way to avoid medications to alleviate their symptoms. Dilation results uniformly in improvement in dysphagia but fails to control the underlying esophageal eosinophilia. Clinical resolution of dysphagia varies after dilation, with symptomatic recurrence occurring within 3–12 months [6, 7] in some, while it is delayed longer than a year in others [8–11]. The main concern with dilation is perforation. However, a meta-analysis suggests that this risk is minimal [12]. Interestingly, a recent cost analysis suggested that dilation was less economical than treatment with swallowed aerosolized steroids in EoE [13]. It should be stressed to patients that the disease itself will not remit with dilation, and topical therapy in addition to dilation should be recommended.
Topical Steroids Steroids offer a medical alternative to dilation for relief. Swallowed aerosolized and viscous steroids have proven efficacy in controlling eosinophilic inflammation of the esophagus. Initial data regarding aerosolized, topical steroids in EoE were from retrospective series of patients with EoE who responded to 220 mcg swallowed twice daily [14]. Subsequent prospective and retrospective series of various dosages have looked at the efficacy of aerosolized fluticasone [15–17]. Liacouras reported his experience with topical steroids in a pediatric cohort of EoE seen between 1994 and 2004. Seventeen patients received from 110 mcg BID to 220 mcg BID of aerosolized fluticasone on the basis of age (more or less than 8 years). Eosinophil counts decreased from 27.7 (5.0) to 11.2 (2.7). Unfortunately, symptoms resolved in only 7/17 (41.2 %) of the patients, and all symptoms recurred after discontinuation of therapy [18]. Konikoff performed the first randomized controlled trial of swallowed aerosolized fluticasone in EoE in 36 children was reported in 2006. Children completed 3 months of swallowed fluticasone (880 mcg a day) or placebo for 3 months. Complete response (defined at
ESOPHAGUS (L GERSON, SECTION EDITOR)
Which Patients with Eosinophilic Esophagitis (EoE) Should Receive Elemental Diets Versus Other Therapies? Kathryn A. Peterson & Kathleen K. Boynton
Published online: 15 December 2013 # Springer Science+Business Media New York 2013
Abstract Eosinophilic esophagitis (EoE) has increasingly been identified in both children and adults. The aim of therapies is to alleviate symptoms while reducing the esophageal inflammation. Mechanical dilation is effective at relieving symptoms, but without the benefit of controlling disease inflammation. Topical steroids appear to be effective at controlling both symptoms and esophageal eosinophilia. Recurrence rates are high once steroids are discontinued. For dietary modification, both the elimination of select, specific foods and the complete elimination of food proteins via amino acid formulas have been looked at. Both forms of dietary modification are effective. Elemental diet, although not an ideal firstline therapy for EoE, provides insight into the etiology of unusual or refractory EoE. The contribution of unusual food antigens to EoE may be determined via the use of amino-acidbased formulas in patients with EoE. Keywords Eosinophilic esophagitis . Esophageal dilation . Topical steroids . Elimination diet . Elemental diet
Introduction Eosinophilic esophagitis (EoE) is characterized by an immune response manifested as eosinophilic inflammation in the esophagus [1–3]. When left uncontrolled over time, the inflammation, involving mast cells (mediators of TGF beta and additional remodeling proteins) as well as eosinophils, results in esophageal strictures, spasms, and subsequent food
impactions [4]. Current therapies focus on alleviating symptoms while reducing histologic inflammation. Various therapies have been attempted to control the inflammation in order to reduce the complications and symptoms of the disease [5]. Treatments studied have focused on mechanical dilation of strictures, altering the effects of specific proteins involved in the pathogenesis of esophageal eosinophilia (biologics), dampening the immune response to such signals (topical steroids), or removing the offending agent that is triggering the reaction (elemental or food elimination diets). The goals of therapy include the following: relief of symptoms, reduction in inflammation, and prevention of strictures and associated complications without causing nutritional compromise. The ACG guidelines for 2013 recommended both steroids (topical) and dietary therapy as effective first-line treatments for EoE and suggested that dietary therapy be tailored to patient needs and available resources [3]. Gastroenterologists should consider both patient preference and efficacy as they decide upon treatment. Biologics are expensive and not currently FDA approved. Optimal dosages for topical steroids have been incompletely characterized, and complications of candidiasis have been reported. Food elimination diets are effective, but compliance is difficult to confirm (especially since the primary patients with EoE are young males who are notorious for compliance issues). Elemental diets (ELEDs) are effective but plagued with concerns over compliance. Below, we will review the most common clinically available therapies for adult EoE and suggest a role for ELED in the therapeutic realm.
This article is part of the Topical Collection on Esophagus K. A. Peterson (*) : K. K. Boynton Division of Gastroenterology, University of Utah, 30 North 1900 East SOM4R118, Salt Lake City, UT 84132, USA e-mail: [email protected]
Dilation Similar to inflammatory bowel disease, chronic, uncontrolled inflammation leads to fixed, fibrotic strictures in EoE over
364, Page 2 of 7
time [4]. In such patients, resolution of dysphagia cannot be completely achieved without undergoing mechanical dilation [5]. Dilation may occur as needed in patients and offers patients a way to avoid medications to alleviate their symptoms. Dilation results uniformly in improvement in dysphagia but fails to control the underlying esophageal eosinophilia. Clinical resolution of dysphagia varies after dilation, with symptomatic recurrence occurring within 3–12 months [6, 7] in some, while it is delayed longer than a year in others [8–11]. The main concern with dilation is perforation. However, a meta-analysis suggests that this risk is minimal [12]. Interestingly, a recent cost analysis suggested that dilation was less economical than treatment with swallowed aerosolized steroids in EoE [13]. It should be stressed to patients that the disease itself will not remit with dilation, and topical therapy in addition to dilation should be recommended.
Topical Steroids Steroids offer a medical alternative to dilation for relief. Swallowed aerosolized and viscous steroids have proven efficacy in controlling eosinophilic inflammation of the esophagus. Initial data regarding aerosolized, topical steroids in EoE were from retrospective series of patients with EoE who responded to 220 mcg swallowed twice daily [14]. Subsequent prospective and retrospective series of various dosages have looked at the efficacy of aerosolized fluticasone [15–17]. Liacouras reported his experience with topical steroids in a pediatric cohort of EoE seen between 1994 and 2004. Seventeen patients received from 110 mcg BID to 220 mcg BID of aerosolized fluticasone on the basis of age (more or less than 8 years). Eosinophil counts decreased from 27.7 (5.0) to 11.2 (2.7). Unfortunately, symptoms resolved in only 7/17 (41.2 %) of the patients, and all symptoms recurred after discontinuation of therapy [18]. Konikoff performed the first randomized controlled trial of swallowed aerosolized fluticasone in EoE in 36 children was reported in 2006. Children completed 3 months of swallowed fluticasone (880 mcg a day) or placebo for 3 months. Complete response (defined at
