• The guidelines support the use of maintenance therapy with topical glucocorticosteroids after remission is achieved on this treatment regimen. This is a conditional recommendation based on very low-quality evidence. However, the “chronicity and potential for disease progression provide the rationale for maintenance therapy of EoE,” as a range of research findings “support the likely chronic nature of symptoms and histopathology of EoE if it either is untreated, or if treatment is discontinued,” the authors wrote.3

“Until more data are available, the continued use of either PPI, topical glucocorticosteroids, or elimination diets are reasonable options, and this is a very preference-sensitive area of management.” This recommendation addresses only topical glucocorticosteroids because of the dearth of evidence pertaining to maintenance with PPI or diet therapies.3

Additional meeting presentations focused on considerations in choosing between dietary management and steroid therapy, as well as the importance of close collaboration between specialists in managing patients with EoE.5,6 Because of “its allergic nature, the increased rates of immediate hypersensitivity, potential complications such as loss of tolerance during food avoidance, and the multiple concurrent allergic diatheses that occur in [patients with] EoE, this is a disease best served by an integrated clinical approach that involves gastroenterologists, allergists, and pathologists,” according to Edmond S Chan, MD, FRCPC, clinical associate professor and head of the Division of Allergy and Immunology in the Department of Pediatrics at the University of British Columbia in Canada.6

For further discussion regarding this and other aspects of EoE management, Pulmonology Advisor interviewed Matthew A Rank, MD, physician and associate professor of medicine in the Division of Allergy, Asthma, and Clinical Immunology at Mayo Clinic in Phoenix, Arizona, and a coauthor of the guidelines.


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Pulmonology Advisor: What are some of the treatment challenges associated with EoE? 

Dr Rank: We have several treatments for EoE that are likely effective — including topical steroids, PPI, elimination diets, and dilation — but we do not have great information about selecting among therapies, combining therapies, and how long we should be treating each person for EoE.

Pulmonology Advisor: What are examples of the most recent developments in our understanding of this disease and its management?

Dr Rank: The mechanism by which specific foods are associated with inflammation in the esophagus remains an active area of investigation, and understanding these mechanisms will hopefully unlock better ways to help patients manage this disease through diet. Treatments directed at the inflammatory mechanisms are emerging — phase 2 and 3 study results for new treatments are encouraging.

Pulmonology Advisor: How should allergists and gastroenterologists work together in managing these patients?

Dr Rank: There are several ways that teams from different areas can work together to provide the best care for people with EoE. We advocate for having clinics where allergy and gastroenterology specialists work directly together, although we recognize that this is often not feasible. We believe it is important to have excellent lines of communication and a common understanding of the evidence available for managing EoE — this helps avoid the situation where patients receive conflicting advice.

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Pulmonology Advisor: What are additional recommendations for clinicians treating people with EoE, as well as remaining research needs in this area?

Dr Rank: We believe that management should start with explaining the harms and benefits of each treatment option, followed by a discussion with the patient to decide what may work best for them. We also think it is important to regularly follow-up with patients, as the initial treatment choices may need to be adjusted. 

There are many gaps in the research that remain, including studies to compare treatment options; longer term studies; studies comparing emerging treatments, noninvasive methods of assessing esophageal inflammation, biomarkers that help select treatment and predict treatment response, and tests that help accurately identify food triggers for esophageal inflammation. 

References

1. Carr S, Chan ES, Watson W. Eosinophilic esophagitis. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):58.

2. Philpott H, Kweh B, Thien F. Eosinophilic esophagitis: current understanding and evolving concepts. Asia Pac Allergy. 2017;7(1):3-9.

3. Hirano I, Chan ES, Rank M, et al. American Gastroenterological Association and the Joint Task Force on Allergy-Immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. Paper presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX.

4. Greenhawt M. EoE guidelines: what has changed and what has not. Practical Applications at Work Seminar: The Updated EoE Guidelines — Whose Disease Is It Anyway? Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX.

5. Rank M. Diet vs steroid — choosing the right therapy. Practical Applications at Work Seminar: The Updated EoE Guidelines — Whose Disease Is It Anyway? Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX.

6. Chan ES. One ring to rule them all: approaches to how the allergist and gastroenterologist can co-manage EoE. Practical Applications at Work Seminar: The Updated EoE Guidelines — Whose Disease Is It Anyway? Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX.