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Combined and Alternating Topical Steroids and Food Elimination Diet for the Treatment of Eosinophilic Esophagitis

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Abstract

Background

Few studies have examined combined or alternating treatment algorithms in eosinophilic esophagitis.

Aims

We conducted a retrospective cohort study to ascertain the efficacy and adherence to a combined and alternating treatment approach with topical corticosteroids and 2-food elimination diet for pediatric EoE.

Methods

Patients were prescribed a 2-food elimination diet (milk and soy) and topical corticosteroid (fluticasone or oral viscous budesonide) for 3 months, after which the steroid was discontinued and 2-food elimination diet continued for 3 months. An EGD was performed at baseline, 3 and 6 months. Clinical, endoscopic, and histologic data were extracted from electronic medical records. Nonparametric tests assessed adherence and outcomes.

Results

Twenty-nine eosinophilic esophagitis cases were included (mean age 11.5 years, 61% male). Complete adherence to combined therapy and 2-food elimination diet alone was 75 and 79%, respectively. Median eosinophil counts decreased from 51 to 2 eosinophils/hpf (p < 0.001) after combined treatment and rebounded to 31 (p = 0.07) after 2FED alone. Dysphagia improved after both the combined and 2-food elimination diet alone treatment approaches (52 vs. 11% and 10%; p = 0.001, 0.005). Nonsignificant improvements in endoscopic findings were documented across the length of follow-up.

Conclusions

An initial combined treatment approach resulted in significant improvements in symptoms and histologic findings. While symptomatic improvements continued with 2-food elimination diet alone, the histologic improvement was not maintained. While loss to follow-up may obscure the efficacy of 2-food elimination diet alone, a combined/alternating treatment approach merits assessment in a larger prospective study.

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Abbreviations

EoE:

Eosinophilic esophagitis

Eos/hpf:

Eosinophils per high-power field

tCS:

Topical corticosteroids

FED:

Food elimination diet

PPI:

Proton pump inhibitor

2FED:

2-food elimination diet

EREFS:

EoE Endoscopic Reference Score

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Funding

This research was supported by NIH Awards T32 DK007634 (CCR) and R01 DK101856 (ESD).

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Authors and Affiliations

  1. Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB #7080, Rm 4140 Bioinformatics Bldg, 130 Mason Farm Rd, Chapel Hill, NC, 27599-7080, USA

    Craig C. Reed, Evan S. Dellon & Elizabeth T. Jensen

  2. Division of Pediatric Gastroenterology, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA

    Anca M. Safta & M. Angie Almond

  3. Department of Pathology and Laboratory Medicine, University of Kentucky School of Medicine, 800 Rose Street, MS141, Lexington, KY, 40536-0298, USA

    Shadi Qasem

  4. Division of Public Health Sciences, Department of Epidemiology, and Prevention, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA

    Elizabeth T. Jensen

Authors
  1. Craig C. Reed
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  2. Anca M. Safta
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  5. Evan S. Dellon
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Contributions

Reed was involved in manuscript drafting; data extraction; data analysis/interpretation; critical revision; Safta and Almond contributed to project conception; data interpretation; critical revision; Qasem performed data interpretation; critical revision; histology interpretation; Dellon helped in data analysis/interpretation; critical revision; Jensen was involved in project conception; supervision; data analysis/interpretation; manuscript drafting; critical revision.

Corresponding author

Correspondence to Elizabeth T. Jensen.

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Conflict of interest

None of the authors report potential conflicts of interest with this study. Dr. Dellon is a consultant for Adare, Alivio, Allakos, Banner, Enumeral, GSK, Receptos/Celegene, Regeneron, Roche, and Shire, receives research funding from Adare, Meritage, Miraca, Nutricia, Receptos/Celgene, Regeneron, and Shire, and has received an educational grant from Banner.

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Reed, C.C., Safta, A.M., Qasem, S. et al. Combined and Alternating Topical Steroids and Food Elimination Diet for the Treatment of Eosinophilic Esophagitis. Dig Dis Sci 63, 2381–2388 (2018). https://doi.org/10.1007/s10620-018-4931-9

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  • DOI: https://doi.org/10.1007/s10620-018-4931-9

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