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Illuminating Elimination Diets: Controversies Regarding Dietary Treatment of Eosinophilic Esophagitis

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Abstract

Eosinophilic esophagitis (EoE) is an immune-mediated disease triggered by food antigens for which dietary elimination treatment can induce and sustain histologic remission. Our review aims to describe the state of the art regarding dietary treatment of EoE, highlighting a number of areas of controversy related to dietary therapy in EoE, including novel modalities for determining food triggers, making the empiric dietary elimination process more efficient, issues of cross-contamination and “dosing” of how much food to avoid or add back, costs and effects on quality of life, long-term efficacy, and the risk of developing immediate IgE-type reactions after initial dietary elimination. Elemental formulas, empiric elimination diets, and targeted allergy test-directed elimination diets are well-described treatments for EoE. Although elemental diets are most efficacious, their clinical use is limited by cost and the palatability of an exclusively liquid diet. While empiric elimination is less effective than elemental formula-based diets, they are more easily implemented and often sustainable. Since the comparative effectiveness of elimination diets with proton-pump inhibitors and swallowed topical steroids remains unknown, there are multiple areas to address with future research.

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Acknowledgments

This paper was supported by NIH R01 DK101856, NIH T32 DK007634, and CEGIR (U54 AI117804) which is part of the Rare Disease Clinical Research Network (RDCRN), an initiative of the Office of Rare Diseases Research (ORDR), NCATS, and is funded through collaboration between NIAID, NIDDK, and NCATS. CEGIR is also supported by patient advocacy groups including APFED, CURED, and EFC.

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

    Cary C. Cotton & Evan S. Dellon

  2. Asthma and Allergy Specialists, PA, Charlotte, NC, USA

    Raquel Durban

  3. Food Allergy Institute of Charlotte, Charlotte, NC, USA

    Raquel Durban

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  1. Cary C. Cotton
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Correspondence to Evan S. Dellon.

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Dr. Dellon has received research funding from Adare, Allakos, GSK, Meritage, Miraca, Nutricia, Celgene/Receptos, Regeneron, and Shire; has received consulting fees from Adare, Alivio, Allakos, AstraZeneca, Banner, Calypso, Enumeral, EsoCap, Celgene/Receptos, GSK, Gossamer Bio, Regeneron, Robarts, Shire, and educational grants from Allakos, Banner, and Holoclara. The other authors have no potential conflicts of interest.

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Cotton, C.C., Durban, R. & Dellon, E.S. Illuminating Elimination Diets: Controversies Regarding Dietary Treatment of Eosinophilic Esophagitis. Dig Dis Sci 64, 1401–1408 (2019). https://doi.org/10.1007/s10620-019-05602-w

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