Milk elimination achieves similar histological remission vs. more restrictive diet in EoE
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The elimination of animal milk alone was an effective first step in dietary therapy for patients with eosinophilic esophagitis, according to research published in The Lancet Gastroenterology & Hepatology.
“A controversy in diet-based therapy for eosinophilic esophagitis is whether to initially exclude a long list of possible food triggers or start with a smaller number of the most common food antigens that trigger esophageal eosinophilia,” Kara L. Kliewer, PhD, of the division of allergy and immunology at Cincinnati Children’s Hospital Medical Center and the University of Cincinnati, and colleagues wrote. “Excluding many potential triggers increases the likelihood that histological improvement will be reached at the cost of markedly restricting diet when eliminating six or more commonly consumed food types.”
They continued, “Although single and multicenter studies have evaluated more and less restrictive diet exclusion therapy in patients with eosinophilic esophagitis, no randomized trials in adults have compared diet strategies.”
In a multicenter, randomized, open-label trial, Kliewer and colleagues analyzed the outcomes of 129 patients (54% men; mean age, 37 years) with active, symptomatic eosinophilic esophagitis who were assigned the six-food elimination diet (6FED) or the one-food elimination diet (1FED) for 6 weeks. Sixty-two patients began 6FED and eliminated animal milk, wheat, egg, soy, fish and shellfish, peanut and tree nuts, while 67 patients started 1FED, removing animal milk alone.
The primary outcome was the proportion of patients in histological remission, defined as peak esophageal count of less than 15 eosinophils per high-powered field (eos/hpf). Other outcomes included the proportion of patients in complete (peak count 1 eos/hpf) and partial (peak counts 10 eos/hfp and 6 eos/hpf) remission, as well as changes from baseline in EoE Histology Scoring System (EoEHSS), EoE Reference Score (EREFS), EoE activity index (EEsAI) and quality of life.
After 6 weeks, patients who did not have a histological response to 1FED had the option to proceed to 6FED, and those without response to 6FED could proceed to topical fluticasone propionate.
Results showed 40% of patients in the 6FED group and 34% in the 1FED group achieved histological remission, with no significant difference between groups at stricter thresholds for partial remission. However, the difference in proportion of patients who achieved complete remission was “significant” at 19% vs. 6%, respectively. Peak eosinophil counts decreased among patients in both groups (geometric mean ratio = 0.72; 95% CI, 0.43-1.2).
Researchers reported no significant differences in mean changes from baseline for EoHSS (–0.23 vs. –0.15), EREFS (–1 vs. –0.6) or EEsAI (–8.2 vs. –3), and minimal change in quality of life scores in either group compared with baseline.
Among patients without a histological response, nine of 21 patients who proceeded to 6FED and nine of 11 patients who switched to fluticasone propionate with an unrestricted diet achieved histological remission.
“The findings reported herein show that 1FED and 6FED had similar efficacy in achieving histological remission and improving multiple metrics of response in this first comparison randomized trial of dietary elimination in adults with eosinophilic esophagitis,” Kliewer and colleagues concluded. “The study shows the benefit of diet therapy as assessed by histological and endoscopic metrics and that diet therapy reverses the underlying disease pathogenesis by correcting the molecular transcriptome associated with eosinophilic esophagitis.”
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