Steroids vs Dietary Therapy to Treat Eosinophilic Esophagitis
Steroids vs Dietary Therapy to Treat Eosinophilic Esophagitis
Purpose of Review. Eosinophilic esophagitis (EoE) is a condition characterized by dense mucosal eosinophilia in conjunction with symptoms of esophageal dysfunction. Since both the incidence and prevalence of EoE are on the rise in both children and adults, understanding the various treatment options available is imperative in choosing the proper treatment for each patient. This article will highlight the major strides in both medical and dietary treatment of EoE in the past year.
Recent Findings. Whereas prior studies have shown that medical therapy with topical corticosteroids is effective in treating EoE, this more recent literature highlights some of the limitations of this approach, raising awareness that development of better drug delivery models is greatly needed. The review also describes the recent advances in the field of dietary therapy for this disease, particularly in adults, and further supports the notion that the pathophysiology of this disease in children and adults is similar, with food antigens driving this disease.
Summary. Both medical and dietary therapy are effective for treating adults and children with EoE. Choosing the optimal treatment approach should be individualized based both on patient goals and on available local resources. Future prospective clinical trials comparing these two treatment modalities are needed to help understand comparable effectiveness as well as to help understand potential predictors of response to treatment and identify optimal therapeutic endpoints.
Recent consensus guidelines define eosinophilic esophagitis (EoE) as a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The most common symptoms of adults with this condition include dysphagia and food impaction. Involvement of allergic mechanisms in the pathogenesis of EoE has been supported by prior studies demonstrating esophageal tissue expression of allergic mediators such as IgE, eotaxin-3, IL-13, IL-5 and esophageal involvement by immune cells, including mast cells, dendritic cells and eosinophils. Furthermore, esophageal eosinophilia is induced in a murine model following allergen exposure. Given the immunological reactivity of the disease, treatment with anti-inflammatory medications such as oral corticosteroids and swallowed topical corticosteroids has been shown to be efficacious in both children and adults.
The concept of food allergens as the main antigenic trigger in EoE was introduced in a landmark study by Kelly and Sampson in pediatric patients with symptoms of gastroesophageal reflux disease (GERD) and histologic features of esophageal eosinophilia, both of which were unresponsive to acid suppression or fundoplication. After treatment with an elemental or amino acid based formula, both symptoms and histologic eosinophilia resolved. Since this landmark study, numerous series have replicated this association of food allergens as a trigger in EoE in both the adult and the pediatric population. Common food triggers found to cause EoE in both children and adults include milk, wheat, soy, egg, nuts/peanuts, and fish/shellfish.
The feasible goals of treatment in EoE are still evolving, but typically include resolution of clinical symptoms, and the achievement and maintenance of histologic remission. Other important goals include prevention of complications of the disease (including fibrostenotic changes such as strictures), avoidance of food bolus impaction and avoidance of esophageal perforation, which can occur either spontaneously (from retching during a food impaction) or iatrogenically (from stricture dilation). Other important therapeutic endpoints include improvement in the patient's quality of life, improvement of nutritional deficits in those treated with dietary restrictions, and prevention of harmful side effects of medications used to treat the disease. This study highlights the recent strides in both dietary and medical therapy over the past year.
Abstract and Introduction
Abstract
Purpose of Review. Eosinophilic esophagitis (EoE) is a condition characterized by dense mucosal eosinophilia in conjunction with symptoms of esophageal dysfunction. Since both the incidence and prevalence of EoE are on the rise in both children and adults, understanding the various treatment options available is imperative in choosing the proper treatment for each patient. This article will highlight the major strides in both medical and dietary treatment of EoE in the past year.
Recent Findings. Whereas prior studies have shown that medical therapy with topical corticosteroids is effective in treating EoE, this more recent literature highlights some of the limitations of this approach, raising awareness that development of better drug delivery models is greatly needed. The review also describes the recent advances in the field of dietary therapy for this disease, particularly in adults, and further supports the notion that the pathophysiology of this disease in children and adults is similar, with food antigens driving this disease.
Summary. Both medical and dietary therapy are effective for treating adults and children with EoE. Choosing the optimal treatment approach should be individualized based both on patient goals and on available local resources. Future prospective clinical trials comparing these two treatment modalities are needed to help understand comparable effectiveness as well as to help understand potential predictors of response to treatment and identify optimal therapeutic endpoints.
Introduction
Recent consensus guidelines define eosinophilic esophagitis (EoE) as a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The most common symptoms of adults with this condition include dysphagia and food impaction. Involvement of allergic mechanisms in the pathogenesis of EoE has been supported by prior studies demonstrating esophageal tissue expression of allergic mediators such as IgE, eotaxin-3, IL-13, IL-5 and esophageal involvement by immune cells, including mast cells, dendritic cells and eosinophils. Furthermore, esophageal eosinophilia is induced in a murine model following allergen exposure. Given the immunological reactivity of the disease, treatment with anti-inflammatory medications such as oral corticosteroids and swallowed topical corticosteroids has been shown to be efficacious in both children and adults.
The concept of food allergens as the main antigenic trigger in EoE was introduced in a landmark study by Kelly and Sampson in pediatric patients with symptoms of gastroesophageal reflux disease (GERD) and histologic features of esophageal eosinophilia, both of which were unresponsive to acid suppression or fundoplication. After treatment with an elemental or amino acid based formula, both symptoms and histologic eosinophilia resolved. Since this landmark study, numerous series have replicated this association of food allergens as a trigger in EoE in both the adult and the pediatric population. Common food triggers found to cause EoE in both children and adults include milk, wheat, soy, egg, nuts/peanuts, and fish/shellfish.
The feasible goals of treatment in EoE are still evolving, but typically include resolution of clinical symptoms, and the achievement and maintenance of histologic remission. Other important goals include prevention of complications of the disease (including fibrostenotic changes such as strictures), avoidance of food bolus impaction and avoidance of esophageal perforation, which can occur either spontaneously (from retching during a food impaction) or iatrogenically (from stricture dilation). Other important therapeutic endpoints include improvement in the patient's quality of life, improvement of nutritional deficits in those treated with dietary restrictions, and prevention of harmful side effects of medications used to treat the disease. This study highlights the recent strides in both dietary and medical therapy over the past year.