Shared Decision-Making, Routine Monitoring Among Best Practices for Managing EoE

Milli Gupta, MD

Credit: University of Calgary

A literature review published in Canadian Medical Association Journal is calling attention to the rising incidence and prevalence of eosinophilic esophagitis (EoE), providing clinicians with a comprehensive overview of the diagnosis, treatment, and management of the chronic inflammatory disease.¹

Most frequently observed in males 5-14 and 20-45 years of age with a family or personal history of type 2 inflammatory disorders, the pathophysiology of EoE is not well understood. Variability in its clinical presentation as well as uncertainties about optimal long-term management strategies currently hinder its diagnosis and management.¹

Seeking to compile currently available information about EoE, Milli Gupta, MD, and Michelle Grinman, MD, MPH, both clinical associate professors at the University of Calgary, gathered guidelines, meta-analyses, and randomized controlled trials for review by searching PubMed from 2013 - May 2023.¹

Of note, investigators focused primarily on publications from 2018 onwards, when pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries reviewed the existing literature and clinical experiences to address concerns about the use of proton pump inhibitors as part of the diagnostic strategy for EoE. Ultimately, they determined proton pump inhibitors effectively reduce esophageal eosinophilia in children, adolescents, and adults, and should thus be classified as a treatment for esophageal eosinophilia due to EoE rather than a diagnostic criterion.²

Pathophysiology and Clinical Presentation

Although the pathophysiology of EoE is not completely understood, it involves an interaction of antigen exposures with host factors, including esophageal-specific genetic variations. Investigators pointed out disruption of the esophageal epithelial barrier appears to be a trigger and dysphagia is the most common symptom. Additionally, most (75%) patients with EoE have ≥ 1 atopic condition, including food or environmental allergies, atopic dermatitis, allergic rhinitis, nasal polyps, or asthma.¹

Despite what is known about potential triggers and symptoms of EoE, investigators noted it can be difficult to differentiate from gastroesophageal reflux disease (GERD) due to a similar prevalence of esophagitis on endoscopy (46% for EoE vs 56% for GERD). However, they referenced a retrospective case-control study that identified predictors suggestive of EoE over GERD as young age, male sex, dysphagia symptoms, and food allergies, additionally clarifying the absence of hiatal hernia, esophageal rings, furrows, plaques, or exudates were more likely to be seen in EoE.¹

Diagnosis and Management

EoE is diagnosed based on both clinical history of esophageal dysfunction and esophageal biopsies showing eosinophilic-predominant inflammation on histology (≥ 15 eosinophils/high power field). Investigators suggested biopsies should be taken at the time of endoscopy due to 10%-32% of patients with EoE having a seemingly normal esophagus.¹

Although current guidelines recommend either pharmacologic or dietary treatment for EoE, investigators pointed out a combination of both should be considered in patients with limited response to a single therapy.¹

Proton pump inhibitors are recommended as a first-line treatment, while topical corticosteroids are suggested for patients who do not respond to first-line therapy or in patients with aggressive disease.¹

Additionally, novel biologic agents targeting key drivers of type 2 inflammation have shown success in the management of EoE. Of note, dupilumab was recently granted approval by the US Food and Drug Administration (FDA) for the treatment of EoE in children 1-11 years of age weighing ≥ 15 kg, expanding upon its prior approval for EoE in patients ≥ 12 years of age weighing ≥ 40 kg.3,4

Beyond pharmacologic approaches to treatment, investigators noted empiric elimination and elemental diets have also shown success in inducing remission. Importantly, they pointed out a single-food elimination diet omitting cows’ milk may be comparable to the 6-food elimination diet encompassing cows’ milk, wheat, soya, nuts, seafood, and eggs for endoscopic, symptom, and histologic remission (34% v 40%; 95% CI, –11 to 23; P <.58).¹

Investigators noted elemental diets, on the other hand, have a limited role in treating EoE and are reserved for patients otherwise refractory to treatment, citing their unpalatability, high cost, and negative impact on quality of life. Additionally, they noted dilation may be necessary in certain scenarios for relieving obstructive symptoms in EoE, but investigators were careful to point out it is not a viable treatment option on its own because it does not treat the underlying inflammation.¹

After starting treatment for EoE, patients should be reassessed after 8–12 weeks, with investigators emphasizing the importance of considering both clinical symptoms and the extent of esophageal healing. Routine clinical and endoscopic follow-up should continue even after remission is achieved, but investigators were careful to note an ideal timeline has not been established.¹

“Shared decision-making is essential to the long-term success of eosinophilic esophagitis care,” investigators concluded, calling for future research about the diagnosis, treatment, and management of EoE.¹

References:

1. ^{Gupta M, Grinman M. Diagnosis and management of eosinophilic esophagitis. CMAJ; 196:E121-8. doi:10.1503/cmaj.230378}
2. ^{Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022-1033.e10. doi:10.1053/j.gastro.2018.07.009}
3. ^{Fitch, J. FDA approves dupilumab for eosinophilic esophagitis in children aged 1 to 11 years. Contemporary Pediatrics. January 25, 2024. Accessed February 2, 2024. https://www.contemporarypediatrics.com/view/fda-approves-dupilumab-for-eosinophilic-esophagitis-in-children-aged-1-to-11-years}
4. ^{Butera, A. FDA Approves Dupilumab for Eosinophilic Esophagitis. HCPLive. May 20, 2022. Accessed February 2, 2024. https://www.hcplive.com/view/fda-approves-dupilumab-for-eosinophilic-esophagitis}