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Budesonide may be more viable first-line therapy than elimination diet, PPIs in EoE
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Many patients diagnosed with eosinophilic esophagitis responded to proton pump inhibitors and were subsequently diagnosed with PPI-responsive esophageal eosinophilia in a recent study. However, those who did have EoE achieved better outcomes with first-line budesonide compared with an elimination diet plus PPIs.
The efficacy of guideline-recommended first-line dietary therapy in patients with EoE has yet to be established “outside of the closely supervised clinical trial setting, in alternative patient groups and followed over long time periods,” Peter R. Gibson, MD, of Monash University and The Alfred Hospital in Melbourne, Australia, and colleagues wrote. “This would seem particularly important given the awkward nature of dietary therapy, the potential for region-specific allergens to alter sensitization and thus therapeutic efficacy, and the unknown mechanism whereby PPIs exert their therapeutic effect.”
Gibson and colleagues evaluated clinical outcomes in patients diagnosed with EoE who were prospectively managed according to a clinical algorithm at Box Hill Hospital and The Alfred Hospital between September 2013 and January 2015. Patients receiving corticosteroids were required to stop 8 weeks before beginning the treatment algorithm.
All patients received 40 mg oral esomeprazole twice daily for 8 weeks and were then evaluated by gastroscopy and biopsy of the esophagus, stomach and duodenum. If their esophageal eosinophil density was less than 15 per high-power field, then PPI-REE was diagnosed. Patients who were not responsive to PPIs were then offered to undergo either a six-food elimination diet with continued PPI therapy, or 1 mg budesonide gel administered twice daily. Repeat gastroscopies and esophageal biopsies were performed at 3 months after disease control was achieved and again at 6 months in the elimination diet group. Treatment success was defined based on histopathology.
One hundred seven patients were included in the analysis, all of whom had been previously treated with PPIs and/or topical corticosteroids (mostly white men; mean age, 37 years). After 8 weeks of PPI therapy, 25 (23%) were diagnosed with PPI-REE, leaving 82 patients with a diagnosis of EoE.
Twenty-nine (52%) of the 56 patients with EoE who chose the elimination diet plus PPIs achieved complete remission, 23 completed dietary reintroduction and 20 (36%) had food triggers identified (most commonly gluten, diary and eggs).
Twenty-three (92%) of the 25 patients with EoE who chose budesonide treatment achieved complete resolution, and of the 27 elimination diet nonresponders, 25 began budesonide therapy and 23 (92%) responded.
More than 85% of all EoE patients had sustained remission with either treatment at 3 months, whereas 55% of elimination diet responders remained compliant and sustained remission at 9 months.
“The current real-world experience suggests that re-evaluation of PPI therapy in those patients presenting with [EoE] may be required both in the durability of resolution of that finding in those deemed to have [PPI-REE], and in its continued use in patients responding to the six-food elimination diet,” the researchers concluded. “The current approach as indicated by clinical practice guidelines warrant further evaluation given the limited initial response to the elimination diet, the cumbersome nature of the diagnostic process and the tendency of patients to cease the diet as determined at 9 months follow-up. In contrast, budesonide will successfully treat more than 90% of patients and few gastroscopies are required, suggesting that the latter is a more viable first-line therapy.” – by Adam Leitenberger
Disclosure: Philpott reports personal funding support from the National Health and Medical Research Council.
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