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Six-food elimination diet helps maintain remission in pediatric EoE
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WASHINGTON — Identifying trigger foods through a six-food elimination diet helped children with eosinophilic esophagitis maintain long-term remission, according to research presented at Digestive Disease Week.
Salvatore Oliva, MD, of the Pediatric Gastroenterology and Liver Unit at the University of Rome, said PPIs, topical steroids and diet are all considered first-line treatment for EoE.
“Despite having great variability in terms of efficacy, ... we do not have comparative studies among these strategies,” he said in his presentation. “We performed a randomized controlled trial to assess the efficacy of the six-food elimination diet and different topical steroids in inducing and maintaining remission of pediatric EoE.”
Oliva and colleagues analyzed data from 50 patients younger than 18 years with active EoE who failed to achieve response to PPI therapy. They randomly assigned patients to receive one of four different treatments: the six-food elimination diet (n = 13), swallowed fluticasone (n = 12), swallowed budesonide (n = 12), and oral viscous budesonide (n = 13). The primary outcome of the study was percentage of responders defined by an eosinophil count of less than 15. Investigators assessed response at week 8 and week 42.
At 8 weeks of follow-up, Oliva and colleagues determined response rates for each group. The rate was 69% for the six-food elimination diet, 67% for swallowed fluticasone, 75% for swallowed budesonide, and 85% for oral viscous budesonide. At the end of the study, the percentage of patients who maintained remission were 61%, 42%, 33%, and 38% respectively.
Oliva said the steroids required repeated cycles to maintain long-term remission, while almost all the children who responded to diet maintained remission in the long-term.
“Surely in the short-term, both diet and steroids are effective in inducing remission,” Oliva said. “The diet is able to maintain remission. This is probably related to the fact that the diet includes both the concepts of induction and maintenance at the same time.” - by Alex Young
Reference:
Oliva S, et al. Abstract 786. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosures: Oliva reports financial ties to Medtronic and Capsovision. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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Joel R. Rosh, MD, FAAP, FACG, AGAF
This was a very interesting study. Currently, we have come to recognize that there are two ways to treat eosinophilic esophagitis, and that’s topical steroids or eliminating foods that are driving the process.
These investigators were ambitious because this was a four-armed study. It probably is not a surprise to anyone who is very familiar and has treated a lot of children and adolescents with EoE, but both treatment options work, but they only work if a patient follows them.
Around 65% to 75% of the patients had a successful induction, whichever therapy was used. This response was still seen at 42 weeks if the patients stayed on the diet or, were given a second round of topical steroids. This study really brings home how we think of treating these diseases. We have options for our patients, they can go on an elimination diet, or they could go on steroids. Either one really needs to be maintained chronically if we’re going to maintain histologic remission. It will open a debate, what our right endpoint is. Does everyone have to achieve histologic remission at all times? We don’t have great natural history data, but we can certainly prevent having symptomatic patients. We can offer them elimination diet or the use of steroids, and the patient could probably go back and forth between these therapies, but to keep our patients in remission, they need to stay on one and this trial adds further evidence to the efficacy of both to maintain, but not to cure the condition.
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