Updated Eosinophilic Esophagitis Guidelines Encourage Interdisciplinary Collaboration

Eosinophilic esophagitis (EoE) affects up to 6 per 10,000 children and adults in North America and Europe, with especially high prevalence rates observed among white males and individuals with atopy and other allergic conditions.^1,2 Various research findings indicate an increasing prevalence of the disease, although the factors driving this increase are unclear.²

Since it was first recognized as a distinct clinical syndrome in 1993, the understanding of EoE has improved substantially.² New guidelines on EoE management were recently developed by the American Gastroenterological Association (AGA) and the Joint Task Force on Allergy-Immunology Practice Parameters (JTE), with the aim of informing treatment decisions among pediatric and adult allergists and gastroenterologists.³

“This collaborative guideline reflects the interdisciplinary nature of EoE that integrates clinical and investigative efforts of multiple domains and builds upon prior consensus recommendations published in both the allergy and gastroenterology literature,” the authors wrote.³ The guidelines were created primarily using the GRADE framework to evaluate the strength of the evidence supporting each recommendation.

EoE was the topic of several presentations that took place in November 2019 at the American College of Allergy, Asthma, & Immunology Annual Scientific Meeting in Houston, Texas. Matthew Greenhawt, MD, MBA, MSc, associate professor of pediatrics at Children’s Hospital Colorado and the University of Colorado School of Medicine, who is one of the authors of the guidelines, provided a summary of the major changes compared with previous versions published by various groups.⁴

In addition to the use of the GRADE methodology, which had not previously been used in JTE recommendations, other new aspects include the following:

• There is now an emphasis on histologic resolution as the key outcome. “The majority of recommendations are based on the failure to achieve histologic remission of <15 eosinophils/high power field as the definition of treatment effect,” as stated in the guidelines.³
• Proton pump inhibition (PPI) is recommended as a first-line treatment option over no treatment. This is a conditional recommendation based on very low-quality evidence, resulting from wide variability in study methodology. Across 23 observational studies, PPI failed to achieve histologic remission in approximately two-thirds of patients vs >85% who received placebo (relative risk [RR], 0.66; 95% CI, 0.61-0.72).³
• “Nevertheless, a clinical benefit to the use of PPI monotherapy may be evident for certain patients,” according to the paper.³ “Based on their long-standing safety profile and ease of administration, patients may prefer to start with this form of therapy prior to trials of glucocorticosteroids or elimination diets.”
• Topical steroids were found to have the most robust supporting evidence compared with other treatment options, and thus received a strong recommendation based on moderate-quality evidence (the strength was downgraded because of study heterogeneity). Based on 8 double-blind placebo-controlled studies (N=437) evaluating the efficacy of topical budesonide or topical fluticasone, these agents failed to achieve histologic remission in approximately one-third of patients vs >85% of patients receiving placebo (RR, 0.39; 95% CI, 0.26-0.58).³ “It is of note that most of these studies required patients first fail a PPI trial or excluded patients with known gastroesophageal reflux disease, which may not reflect routine clinical practice or the most current consensus-driven recommendations.”³
• The testing-based diet has been deprioritized as a treatment option because of lack of clear benefit and very low certainty of evidence. However, this approach is still conditionally recommended over no treatment, as are other dietary strategies such as the elemental diet (moderate-quality evidence) and the empiric 6-food elimination diet (low-quality evidence).³

“Choice of diet style likely does not matter — in the end these all have very low certainty of evidence and none are controlled against a true placebo arm for efficacy,” Dr Greenhawt concluded.⁴ Each of the diet recommendations “come with a modifier to engage in shared decision making with the patient regarding risks, benefits, and preference — diet is preference-sensitive care.”