Investigators evaluated long-term outcomes among individuals who have eosinophilic esophagitis (EoE) and initiated first-line treatment with a food elimination diet after experiencing remission following stoppage of proton pump inhibitor monotherapy.
Fifty-nine percent of patients remained in remission with their eosinophilic esophagitis (EoE) after ceasing proton pump inhibitor (PPI) monotherapy and initiating a food elimination diet (FED), signaling the latter’s potential as an alternative treatment option for individuals living with the chronic inflammatory condition.
Histologic remission of EoE is typically measured at fewer than 15 eos/hpf and then only after several weeks of treatment. For this analysis, the authors used International Classification of Disease, 10th Revision code K20.0 and a measure of 15 or more eos/hpf seen from esophageal biopsies through esophagogastroduodenoscopy (EGD).
Findings published recently in BMC Gastroenterology, with the study authors noting, “Current guidelines suggest patients with EoE should continue any responsive first-line monotherapies. However, the efficacy of FED monotherapy in patients with EoE responsive to PPI monotherapy has not been well studied.”
Their retrospective analysis included 22 patients (median [SD] age, 34.0 [29.2-39.7] years; 59.1%, male patients) who tried FED monotherapy, with quantitative outcomes obtained via a long-term observation and qualitative outcomes through patient surveys. In phase 1, the authors performed a chart review to identify patients who had attempted an FED and achieved histological remission following 8 weeks of PPI monotherapy. Phase 2 saw patients voluntarily enroll. In both phases, patients were classified into 2 groups: responded to PPI treatment but not an FED and responded to PPI treatment and an FED.
In both phases, the most common atopic comorbidities were any atopic condition and allergic rhinitis. Omeprazole 40 mg twice daily was the most common PPI monotherapy, and a 2-food FED (daily and what) was the most common FED.
Phase 1 saw patients with a histologically confirmed median (IQR) eosinophil count of 47.4 (26.25-83.75) eos/hpf at diagnosis, and 81.8% had dysphagia. During PPI monotherapy, dysphagia was also the most common symptom and median peak eosinophil count was 2.5 (0.0-6.0) eos/hpf via EGD. When all patients trialed subsequent FED monotherapy, 68.18% were asymptomatic, heartburn was the most common symptom (22.73%), and median peak eosinophil count was 10.0 (2.25-30.0) eos/hpf. Of the 22 patients, 9 did not achieve histologic remission from the FED; the remaining 13 patients had a median peak eosinophil count of 6 (1-10) eos/hpf vs 38 (20-85) eos/hpf at baseline.
Fifteen patients enrolled in phase 2, and of this group, 6 had responded to PPI monotherapy in phase 1 but not the FED. These patients resumed the PPI treatment and the patients who responded to the FED had 3 choices: PPI monotherapy, continue FED monotherapy, or initiate FED monotherapy with PPI as needed. Median follow-ups were 2.25 (1.51-2.48) and 1.08 (0.73-2.38) years, respectively. No patients reported histologic reactivation of EoE, but 8 reported repeat EGD “for histologic reevaluation of other treatment plans,” the authors noted, after which they restarted their maintenance treatment plans.
Top concerns the 15 patients cited for trying FED monotherapy were long-term medication use (60%), suspected adverse effects from PPI treatment (13.33%), and wanting to know their food triggers (20%). Ninety-three percent also said they would recommend the study’s treatment evaluation process, and 80% said they would go through the process again. Among the 9 patients who responded to both PPI and FED monotherapy, 55.6% continued FED monotherapy. The most common reason given for continuing their maintenance treatment was ability to sustain it (66.7%), with 55.6% also noting trialing an FED increased their overall quality of life.
The authors highlighted that they took up this investigation because there are few recommendations on how patients with EoE can maintain histologic control after effective first-line treatment and a lack of research on maintenance treatment for EoE. They also noted that their findings add to the current literature in this space because they “emphasize options for patients after histologic remission of EoE is achieved.”
“Our study highlights that clinical management guidelines for EoE should be extended past identifying a single treatment plan that induces remission of EoE.”
Extrapolating these findings to a larger audience is limited by the small sample size and patients coming from a single medical center.
Sia T, Cunningham E, Miller M, et al. Food elimination diet is a viable alternative therapy for eosinophilic esophagitis responsive to proton pump inhibitors. BMC Gastroenterol. 2023;23(1):60. doi:10.1186/s12876-023-02703-9