FOOD ELIMINATION DIETS ARE EFFECTIVE FOR LONG-TERM TREATMENT OF ADULTS WITH EOSINOPHILIC OESOPHAGITIS

FCAAIA Notes: There is still a great deal of debate about the best way to treat eosinophilic esophagitis (EoE).  I believe that debate will continue because one size does not fit all.

When an individual food or a limited number of foods are identified as triggers, the avoidance diet might be sufficient.  For others, nothing but extreme dietary intervention (few or no solids and an amino acid based formula) is very useful. That is an unpleasant and impractical alternative. Topical esophageal steroids (e.g., steroid inhalers or nebulizer medications that are swallowed, not inhaled) are the first choice of medications for EoE.

So what foods to eliminate when trying? I think there are several reasonable approaches that need to be individualized for the patient. Sometimes we try the six food elimination diet (really, an eight food elimination diet: milk, egg, wheat, soy, peanut, tree nuts, fish, and shellfish). Sometimes we test for those major food allergens and eliminate those to which there is a positive test, sometimes we also eliminate dairy independent of the test results.  Sometimes we eliminate foods that consistently trigger symptoms, with or without testing first.  All of these options are based on previously publishes studies.

If you have EoE, work with your allergist to find the most diversified yet tolerated diet you can.

(Source: https://www.medscape.com/viewarticle/887688?nlid=119225_3821&src=WNL_mdplsfeat_171128_mscpedit_aimm&uac=112079PK&spon=38&impID=1494393&faf=1 Nov. 28, 2017, from Aliment Pharmacol Ther. 2017;46(9):836-844..For Medscape articles: User name: FCAAIA, Password: Allergies)

Abstract

Background: Limited data describe the long-term efficacy of dietary elimination in eosinophilic oesophagitis (EoE).

Aim: To assess the long-term outcomes of food elimination diets  for treatment of adults with EoE.

Methods: We conducted a retrospective cohort study at our centre analysing all EoE patients receiving a food elimination diet without concomitant steroids. Baseline data were abstracted using standardised collection forms. Follow-up data from a mean 24.9-month period were collected for patients with a histological response to a food elimination diet during and after food reintroduction. The main outcomes were symptomatic, endoscopic and histological responses.

Results: Of 52 patients, 18 received a 6-food food elimination diet, 32 received targeted diet, and two received a 6-food food elimination diet  with targeted elimination. There were 21 (40%) patients with an initial histological response. Responders reported less dysphagia after treatment (95% baseline vs 11%; P = .001) and at the end of follow-up (95% baseline vs 33%; P= .008). Significant and durable endoscopic improvements were recorded at the same time points: Endoscopic reference score: 3.2 vs 0.7; P = .001; and 3.2 vs 1.7; P = .06. Histological findings improved after the most restrictive diet in responders (49.8 vs 4.1 eosinophils per high-power field; P = .001) and remained suppressed in the 10 initial responders maintaining compliance at the end of follow-up (5.2 eosinophils per high-power field).

Conclusions: Among EoE patients responding to a food elimination diet and remaining adherent, maintenance dietary therapy produced durable long-term symptomatic, endoscopic and histological disease control. These long-term data confirm that a food elimination diet is an effective maintenance treatment option in select adults with EoE.

Introduction:

Eosinophilic oesophagitis (EoE) is a chronic immune/antigen-mediated clinicopathologic disorder defined histologically by eosinophilic-predominant oesophageal inflammation and clinically by oesophageal dysfunction. It is diagnosed when there are at least 15 eosinophils per high-power field (eos/hpf) on oesophageal biopsies and after exclusion of alternative aetiologies of eosinophilia. EoE represents a major cause of oesophageal morbidity. The pathogenesis of EoE is multi-factorial, but clinical, histological, and endoscopic improvement with dietary elimination strategies supports the role of food antigen sensitisation in the aetiology of the disorder.

While corticosteroids improve both the clinical and histological features of EoE, there are appreciable rates of nonresponse to steroids, side-effects are possible, and EoE disease  activity recurs after discontinuation of these drugs. In contrast, food elimination diets (FEDs) address the aetiologic triggers of EoE, lack adverse side effects associated with medication, and may produce long-term remission. This makes dietary elimination an attractive treatment option. However, as compared with children, little is known about the long-term efficacy of this treatment strategy in adults.

Therefore, this study aimed to assess the overall long-term efficacy of FEDs in adults for treatment of EoE. We also aimed to evaluate the effectiveness of a FED in patients previously treated for EoE with topical steroids.

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