Guidelines update management of eosinophilic esophagitis

New guidelines from the American Gastroenterological Association and the Joint Task Force for Allergy-Immunology Practice Parameters provide recommendations for the management of eosinophilic esophagitis (EoE) in pediatric and adult patients. They were jointly published in the May issues of Gastroenterology and Annals of Allergy, Asthma and Immunology.

Among the recommendations for patients with EoE are the following.

• In symptomatic patients, use proton-pump inhibitors over no treatment (conditional recommendation, very low-quality evidence).
• Use topical glucocorticosteroids over no treatment (strong recommendation, moderate-quality evidence).
• Use topical glucocorticosteroids rather than oral glucocorticosteroids (conditional recommendation, moderate-quality evidence).

The guidelines also recommended using an elemental or empiric, six-food elimination diet over no treatment, with the understanding that patients who put a higher value on avoiding the challenges of these treatment options may reasonably decline them (conditional recommendations, moderate- and low-quality evidence, respectively). They recommended an allergy testing-based elimination diet over no treatment, knowing that due to the potential limited accuracy of currently available allergy-based testing for specific food triggers, patients may prefer alternative medical or dietary therapies to an exclusively testing-based elimination diet (conditional recommendation, very low-quality evidence).

For patients who are in remission after short-term use of topical glucocorticosteroids, the guidelines recommend continuing therapy. Patients who put a high value on avoiding long-term topical steroid use and its possible associated adverse effects and place a lower value on the prevention of recurrent dysphagia, food impaction, and esophageal stricture could reasonably prefer stopping treatment after initial remission if clinical follow-up is maintained, the guidelines said (conditional recommendation, very low-quality evidence).

In adult patients with dysphagia from a stricture, endoscopic dilation is recommended over no dilation. This treatment does not address the esophageal inflammation associated with EoE (conditional recommendation, very low-quality evidence).

The guidelines' authors noted a common theme in both the guidelines and the accompanying technical review: Clinical trials with more uniform end points are needed to allow better comparisons of therapies. “Furthermore, a deeper understanding of the natural history of EoE in both children and adults is needed to inform clinical decisions regarding the optimal use of disease monitoring and long-term, maintenance therapy,” the guidelines concluded. “In the dawn of this new disease, much light has been shed and the future is bright.”