Pharmacological interventions allow patients with EoE to continue oral immunotherapy
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Key takeaways:
- Ten of 13 patients on OIT who developed eosinophilic esophagitis continued treatment.
- EoE treatment included high-dose and low-dose protein pump inhibitors and swallowed topical corticosteroids.
Most patients who developed eosinophilic esophagitis during oral immunotherapy experienced resolution in their EoE symptoms without stopping OIT, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
When EoE develops, providers should consider halting OIT after pharmacologic treatment fails, Na’ama Epstein-Rigbi, MD, Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, and colleagues wrote.
“While non-immediate gastrointestinal adverse reactions are quite common during OIT, the actual findings of EoE are rarer and more controversial,” Epstein-Rigbi told Healio.
Epstein-Rigbi said that she and her colleagues have noticed a difference between patients who develop gastrointestinal complaints at the initial stage of OIT and those who develop complaints at late stages.
“I also found that in all research I read, patients with EoE were compelled to stop treatment,” Epstein-Rigbi continued. “We do not automatically stop treatment, and we find that patients reach good outcomes, both in EoE resolution and in desensitization. All these put together drove me to research this topic and analyze all our data.”
The researchers reviewed the charts of 1,994 patients (median age, 7.4 years) with proven IgE-mediated food allergy who received OIT between April 2010 and May 2021, finding 13 patients (0.7%; median age, 13 years) who developed EoE after OIT treatment began.
“The prevalence of OIT-associated EoE was found to be less than 1%, a prevalence much lower than described in medical data,” Epstein-Rigbi said.
Ten of these patients with EoE were male. Nine of these patients were treated for milk allergy, two for sesame allergy, one for cashew allergy and one for walnut allergy. Also, 85% had a history of atopic comorbidities such as asthma, allergic rhinitis or multiple food allergies.
Four patients developed EoE during the updosing phase, with the others developing it during the maintenance phase. The median interval between OIT initiation and gastrointestinal symptom onset was 25 months (range, 7-84 months).
“Most EoE patients developed symptoms in the late stages of OIT, commonly after reaching the maintenance dose, some even several years after,” Epstein-Rigbi said.
Symptoms included abdominal pain (n = 6), dysphagia (n = 4), nausea (n = 4), vomiting (n = 2), dyspepsia (n = 2) and chest pain (n = 1).
Once these patients were diagnosed with EoE, 12 of them continued consuming their allergen per OIT protocol. The patient who discontinued treatment, who was on milk OIT, did so before initiating EoE treatment due to concurrent anaphylactic reactions. This patient experienced complete resolution of symptoms.
Eleven of the patients who continued with the OIT protocol received 40 mg or 1 mg/kg of omeprazole twice a day via protein pump inhibitor (PPI). The twelfth patient had mild symptoms and no macroscopic findings before experiencing complete resolution of symptoms.
“Most patients were managed solely by pharmacological treatment, mostly proton pump inhibitors, without stopping OIT. Their outcome was good,” Epstein-Rigbi said.
Five of the patients receiving PPI treatment saw complete clinical and histologic resolution, with dosage reduced to once a day. Of the six patients who did not achieve complete histologic resolution, two were treated with 1 mg of swallowed topical corticosteroids twice a day, two continued low-dose PPI, and two patients on OIT for milk allergy stopped their OIT treatment.
Clinical symptoms of EoE resolved for 12 of the patients. The thirteenth patient continued to experience dyspepsia, which the researchers attributed to a hiatal hernia, and continued receiving PPI.
“This is a novel finding, since almost all reports are adverse for stopping OIT,” Epstein-Rigbi. “It is also extremely significant for patients, knowing that even developing EoE does not necessarily damage OIT success or risk their health.”
After treatment, all the patients had an esophagogastroduodenoscopy (EGD), with normal macroscopic findings for the full cohort. Five patients experienced substantial decreases in tissue eosinophilic count, although these counts ranged from 18 to 25 maximum per high-power field.
Overall, the researchers determined that six of the 11 patients treated pharmacologically had complete clinical and histological resolution, whereas five achieved full clinical but only partial histologic resolution. Also overall, 10 of the 13 patients in the cohort continued their OIT treatment.
The researchers further noted that there is no consensus definition for nonimmediate gastrointestinal reactions among patients on OIT and that OIT might not be the cause of eosinophilic infiltration.
For example, the researchers said, approximately 8% of patients on OIT develop OIT-induced GI eosinophilic reactions that can be managed by reducing the allergen dose without EGDs or pharmacological treatment.
With joint management with gastroenterologists, the researchers said, patients who develop symptoms in OIT-associated EoE can be treated pharmacologically while considering whether they will continue with OIT, although they add that OIT cessation should be considered once pharmacological treatment fails.
“I hope that doctors, both allergists and gastroenterologists, will not advise automatically for all patients with OIT-associated EoE to stop therapy. I hope they encourage them to start pharmacological treatment while continuing OIT,” Epstein-Rigbi said. “This should be a joint decision between all caretakers and patients.”
Next, Epstein-Rigbi aims to further describe and analyze patients with OIT-associated EoE both clinically and on a histological and molecular basis. Also, she is reviewing all the data of patients who have been treated with OIT at her institute since 2010 to compare those with non-immediate gastrointestinal complications that developed during the early stages of OIT with those who developed complications during the advanced stages.
“I believe they suffer from two different entities and want to further describe and define them, as well as examine the most favorable treatment approach for each entity,” she said.
For more information:
Na’ama Epstein-Rigbi, MD, can be reached at naamaepstein@gmail.com.