ACG releases updated EoE guideline

The American College of Gastroenterology (ACG) recently released an updated clinical guideline on diagnosis and management of eosinophilic esophagitis (EoE).

Since the organization's 2013 guideline on this topic, “there have been paradigm-shifting changes in disease diagnosis and management, increases in knowledge about EoE risk factors, natural history, and pathogenesis, development of validated outcome metrics, a disease severity classification system, and updated nomenclature,” the guideline panel wrote. The updated guideline aims to create practical, evidence-based recommendations that include new evidence and are actionable across a range of patients and practice settings, they said. The updated guideline was published in the January American Journal of Gastroenterology.

EoE should be diagnosed based on the presence of symptoms of esophageal dysfunction and at least 15 eosinophils per high-powered field on esophageal biopsy, after evaluation for non-EoE disorders that cause or potentially contribute to esophageal eosinophilia (strong recommendation, low-quality evidence), the guideline recommended. A systematic endoscopic scoring system should be used to characterize endoscopic findings of EoE at every endoscopy, and at least six esophageal biopsies from at least two esophageal levels (e.g., proximal/mid and distal) should be obtained, targeting EoE endoscopic findings, if possible, to assess for histologic features consistent with EoE, the guideline said (strong recommendations, low-quality evidence). Eosinophil counts should be quantified on esophageal biopsies from every endoscopy performed for EoE, according to the guideline (strong recommendation, low-quality evidence).

Regarding EoE treatment, the guideline suggested proton-pump inhibitors (PPIs) (conditional recommendation, low-quality evidence) and recommended swallowed topical steroids (strong recommendation, moderate-quality evidence). An empiric food elimination diet is suggested as treatment (conditional recommendation, low-quality evidence), but the guideline does not suggest basing such diets on currently available allergy testing (conditional recommendation, very low-quality evidence).

Regarding biologics, the guideline suggests dupilumab in those ages 12 years and older who have no response to PPIs (conditional recommendation, low-quality evidence) and suggests against using omalizumab (conditional recommendation, low-quality evidence) but could not recommend for or against cendakimab, benralizumab, lirentelimab, mepolizumab, or reslizumab. The guideline suggested against cromolyn and montelukast (conditional recommendation, very low-quality evidence).

The guideline also offered recommendations on esophageal dilation, maintenance therapy, and monitoring and evaluation of treatment response, as well as pediatric-specific recommendations. An algorithm to guide EoE treatment was included.

The guideline authors noted several areas where further research is needed, including comparative efficacy studies to inform monitoring and predicting treatment response, development of novel methods for identifying food triggers, and studies on matching disease severity with treatment and monitoring paradigms. Despite these and other needs, the authors wrote, “tremendous advancements have been made in the field over the past decade to the benefit of both patients and providers, and the field is poised for more advances in the coming years.”