In Treating Eosinophilic Esophagitis, Begin by Removing Milk

Ever since the initial identification of eosinophilic esophagitis (EoE), this disease has been characterized as a non–immunoglobulin E (IgE)–mediated food allergy. As such, selective dietary elimination has been recommended as a standard of care for both pediatric and adult patients with this disease.

The top food allergens targeted in the six-food elimination diet (SFED) used in EoE are milk, soy, eggs, wheat, peanuts/tree nuts, and shellfish/fish. Adherence to this diet among patients with EoE reportedly ranges from being variable to poor, with multiple reasons accounting for this. In addition, sequential reintroduction with repeat endoscopy and biopsy to assess response is inconvenient and time-consuming and can incur significant direct and indirect costs.

Studies have demonstrated that the efficacy of elimination diets is similar to topical steroids, although comparative trials are lacking. In a recently published retrospective review of a large series of adults with EoE, investigators reported that the majority (58%) achieved a histologic response after the use of either initial or extended SFED. Of note, 69% of these patients had just one food trigger identified.

Even though dietary approaches are effective, clinicians may be wary of recommending them. Recent survey data indicate that clinicians view dietary approaches as the least-effective strategy and prefer to use medications. However, advising clinicians on the latest data regarding different, simpler forms of dietary elimination may help address some of this reticence.

A Simpler Strategy of Eliminating Milk Alone

Milk is the most common of the six foods to be allergenic, and recent data have shown that selective milk-only elimination has comparable efficacy to the SFED diet. Yet, compliance with a milk-free diet has associated problems, given the widespread availability of dairy in many food products.

However, of note, studies have demonstrated that children with IgE-mediated hypersensitivity to milk products are able to tolerate baked milk products.

This concept was explored further in a recent prospective study, which included 18 patients (72% male; mean age, 32 years) for whom cow's milk was a demonstrated EoE trigger. For 10 of these patients, milk was the only food trigger, whereas the other eight patients had an additional identified food trigger (eg, legumes, wheat, fish/seafood). All patients were allowed to ingest sterilized cow's milk, which was prepared by subjecting to temperatures > 100 °C for 20 minutes. This is in contrast to standard processed milk, which is heated to 138-145 °C for 2-10 seconds.

Gel electrophoresis — a method used to separate out molecules such as proteins — showed that there were significant changes evident between the two milk preparations, although the casein bands were preserved in both. Patients were asked to consume at least 200 mL of the sterilized cow's milk during the 8-week study. All patients were previously shown to be nonresponders to proton pump inhibitors.

The primary outcome of maintenance of histologic remission (< 15% eos/hpf) was maintained in 12 patients (66.7%). Dysphagia symptom scores, endoscopic appearances, IgE serum levels, and eosinophile counts were all unchanged in these patients. Dietary questionnaires were completed in 16 patients and demonstrated significantly increased ingestion of saturated fatty acids, medium chain triglyceride, and calcium in the remission group.

Although this is a small single-center study, it was remarkably well done and used clearly characterized patients with milk sensitivity and EoE.

An Actionable Approach

Despite the finding that clinicians view dietary therapy as the least-effective treatment for EoE, such approaches nonetheless have efficacy and are likely a much better option in terms of cost-effectiveness and safety profile.

Involvement of a dietician is inordinately helpful in promoting patient understanding as well as enhancing and assessing compliance. Patients with EoE value reportedly infrequently experience the opportunity for shared decision-making in their treatment. Given the expense of the new treatments for EoE, healthcare providers should strongly evaluate and offer a dietary approach.

With these new findings on milk sensitivity and the remarkable tolerance when it is temperature prepared, we are perhaps moving away from the extreme restrictions of SFED and toward approaches with both better patient acceptance and excellent clinical outcomes in patients with EoE.

It is clear that more studies on milk preparation are needed to confirm these promising results, but this approach may be actionable now.

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.

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