AGA issues new guidelines on eosinophilic esophagitis
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The American Gastroenterological Association published new guidelines focused on the treatment of children and adults with eosinophilic esophagitis.
The AGA partnered with the Joint Task Force for Allergy-Immunology to provide recommendations on management of these patients, including which therapies should be prioritized.
“Over the past two decades, EoE has emerged as a dominant cause of swallowing difficulties worldwide,” Ikuo Hirano, MD, from Northwestern University Feinberg School of Medicine, said in a press release. “The recommendations we’ve outlined will guide allergists and gastroenterologists in effectively managing their patients’ EoE and improving their quality of life. As the field moves forward, a deeper understanding of the natural history of EoE in both children and adults is needed to inform clinical decisions regarding the optimal use of disease monitoring and long-term, maintenance therapy.”
Key highlights of the guideline include:
Topical steroids are recommended as first-line treatment for EoE
For patients with EoE, the AGA recommended topical steroids over no treatment. It is the only strong recommendation given in the new guidelines.
In their review, the guideline authors identified studies that compared treatment with topical fluticasone or budesonide with placebo. In these trials, topical steroids failed to induce histologic remission in about one-third of patients, compared with more than 85% of patients treated with placebo (RR = 0.39; 95% CI, 0.26-0.58). Patients treated with topical steroids also experienced no increased risk for adverse events.
Although no medications have received FDA approval for EoE, they are regularly used in clinical management of the disease and are considered safe for use in patients with asthma.
The guidelines also support topical steroids over oral glucocorticosteroids.
Proton pump inhibitors, diet therapy, esophageal dilation also recommended
While approximately two-thirds of patients with EoE do not respond to PPIs, guideline authors still gave them a conditional recommendation.
“PPIs are positioned as an effective, primary therapeutic option for certain patients with EoE,” they wrote. “Based on their longstanding safety profile and ease of administration, patients may prefer to start with this form of therapy before trials of glucocorticosteroids or elimination diets.”
However, they recommended both an empiric, six-food elimination diet and an allergy testing-based elimination diet over no treatment. In patients with esophageal strictures, authors recommended periodic dilation as necessary in combination with medical and dietary therapies.
More research is needed before targeted biologic therapies can be recommended
Guideline authors wrote that biologic therapies are currently being evaluated, and agents such as anti-interleukin-5, anti-IL-13 and anti-IL-4-receptor-alpha should only be used in the context of a clinical trial.
Perspective
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Scott Gabbard, MD
AGA and the Joint Task Force for Allergy-Immunology did a very nice job, especially by jointly releasing these guidelines. The guidelines underscore the importance of gastroenterologists working together with allergists for patients with EoE. In my practice, I share many patients with our allergists, and find their input to be quite helpful for our patients. The patients themselves benefit by having each specialty weigh in on what therapy and course of action to take.
The guidelines have made clear recommendations for the use of topical corticosteroids, PPIs, and diet in the treatment of EoE. The guidelines recommend continuing with maintenance therapy for patients who achieve remission with topical corticosteroids. Importantly, the guidelines recommend biologic therapy (anti- IL-4, IL-5, IL-13, TNF) only in the context of a clinical trial.
Additionally, the guidelines recommend endoscopic dilation for patients with esophageal stricture. I would like to point out that gastroenterologists often over-estimate esophageal diameter in patients with EoE and may miss subtle rings or mild diffuse narrowing of the esophagus. In my own practice, even if the patient has a normal appearing esophagus, I have a low threshold to perform empiric dilation with a medium sized bougie (~15mm), re-insert the scope after dilating, and slowly increase dilator size until I see a mucosal disruption.
There is currently no FDA-approved therapy for EoE. These AGA guidelines have clear recommendations that advise on the use of both PPIs and topical corticosteroids. I am now using those guidelines in my clinical practice. Recently, I have started the habit of including these guidelines with my prior authorization forms, with copies sent both to the insurance company and the patient – with a reminder that these are guidelines from the AGA. I find that these recommendations give strength to my argument for payers to cover these medications until there is FDA-approved therapy. These guidelines can help our cause to get these medications approved by payers.
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