COMMENTARY

New Eosinophilic Esophagitis Guidelines: What You Need to Know

David A. Johnson, MD

Disclosures

June 05, 2020

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Eosinophilic esophagitis (EoE) was not something that we even considered when I was in training, as it was then thought to be a pediatric disease. In the 1980s, one of the godfathers of the esophagus, Dr H. Worth Boyce, referred to the endoscopic appearance of what we now call EoE as congenital esophageal stenosis. By the 1990s, EoE was considered more of an adult disease. Subsequent to that transition, EoE began to be widely reported on in the literature.

A practical guideline has just been published by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters, which offers helpful tips on how we can best manage the increasing number of patients with EoE. The guidelines were accompanied by a technical review explaining how the recommendations were determined. I'd like to share with you the most newsworthy points from these guidance documents.

Defining Remission

The first consideration is how these guidelines define remission and therefore measured the efficacy of various interventions. The guidance considers the failure to achieve histologic remissions of < 15 eosinophils per high-power field as the gold standard for defining treatment effect, even though it's something we don't always do.

Weighing the Value of Proton Pump Inhibitors

The first question that the guidelines considered was whether proton pump inhibitors (PPIs) should be used in patients with EoE. There certainly was a bevy of information about PPI-responsive EoE to review. Both a European group and a recent international consensus conference have removed the PPI trial from the diagnostic criteria of EoE. Symptomatic esophageal eosinophilia is now viewed as morphologically the same disease as EoE.

The role of PPIs as a treatment option for patients with EoE certainly seems pragmatic. The guidelines recommended its use, although it was conditional given that the overall evidence was very low quality and that prospective studies have not been done.

Glucocorticosteroids

Glucocorticosteroids have certainly been studied extensively, in both systemic and topical form. The esophageal delivery via inhalation or swallowing, as we see with fluticasone, has been reported to be efficacious. Overall, the topical therapies work about two thirds of the time.

The authors noted that although there are currently no approved medications for EoE in the United States, the European Medicines Agency approved a budesonide tablet in 2018. Those who attended the virtual Digestive Disease Week in May 2020 may have seen the phase 3, 12-week, randomized, multicenter, double-blind, placebo-controlled trial looking at oral budesonide suspension at 2 mg twice a day. The results were good, not great. Histologic improvement was significantly different, with 53% for budesonide vs 1% with placebo. The symptomatic scores were not hugely different at 53% vs 39% but again showed a statistically significant advantage for budesonide. Although this is not the silver bullet we're looking for, we nonetheless look forward to hearing more to come on this. It certainly makes things easier for us to have another treatment option.

Elemental vs Elimination Diets

Elemental diets work great in about 95% of kids, but I just don't think it's a pragmatic recommendation in adult patients. These recommendations state that it works better than nothing.

Something that I think is pragmatic, however, are elimination diets. The guidelines specifically recommend the six-food elimination diet, which certainly makes sense, although they note that it could be considered a more-complicated eight-food elimination diet if you include peanuts and tree nuts and then finned fish and shellfish.

When I do talk to my patients about elimination diets, I always have a dietitian see them. But if you're going to do this pragmatically, the recommendations here state to begin with the two most common foods: wheat and milk. You can then expand that list by adding legumes, soy products, eggs, and others as needed.

Esophageal Dilation

Initial reports have suggested that complications increase when esophageal dilation is performed in patients with EoE. However, when the accompanying technical review for this guideline was performed, it showed no mortality associated with dilation. The pooled rate of perforation was 0.4%, hospitalization was 1.2%, and significant gastrointestinal bleed was 0.1%.

The guidelines state that dilation is clearly helpful in adult patients with dysphagia from a stricture associated with EoE. However, you should go slow when you look at mucosal disruption, and stop at the point of significant disruption.

The one additional pearl of advice I'll give you, which the recommendations briefly mention, is to tell your patient about chest pain. About three quarters of these patients will have chest pain after a dilation, which is different from our standard reflux esophagitis. Warn them about chest pain upfront, because otherwise they may not be prepared and start calling you back after the procedure.

Emerging Therapies

The guidelines also discuss a number of new treatment approaches, including interleukin-4, -5, and -13, a variety of immunomodulators, and eosinophil release inhibitors. The guidelines recommend using these treatments only in the context of a clinical study.

Endoscopic Evaluation and Medical Therapy

The final question of note was whether repeat esophagogastroduodenoscopy (EGD) should be used to assess patients with EoE after a change in treatment. Histology is a better predictor, as their symptoms don't always agree with the endoscopic appearances. Although it's not a formal recommendation, they suggest that repeat EGD with biopsy would be reasonable and ideal.

I think the reason this recommendation is a bit of a "soft sell" is that it is really not pragmatic. You're not going to get the patients back that many times, and much less get insurance companies to pay for it. However, I think it's reasonable to assess, in particular for patients who have fibrostenosis. I would consider the pedigree of the patient (eg, how they present, what you see endoscopically, how they respond to dilation) as really driving the prioritization here for repeat assessment as you start to do interval changes.

Regarding medical interventions, the authors recommend against maintenance therapy, perhaps with the exception of diet and the PPIs. Glucocorticosteroids obviously have a systemic effect, potentially even on topical therapies, and should be viewed as a short-term therapy subject to clinical judgment.

These guidelines offer a very nice summary, even though there's not a lot of absolute axiomatic recommendations. That means we still have to apply some clinical judgment when it comes to treating patients with EoE. We'll learn more as we see more of these patients.

This is Dr David Johnson. Thanks again for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....