Air Force, Army, Navy Concentration, Symptom-Based Elimination (A-FANCSE) Diet for Eosinophilic Esophagitis

Abstract

Introduction: Eosinophilic Esophagitis (EoE) is an allergen/immune-mediated esophageal disease that causes esophageal symptoms. Studies have demonstrated that empiric food antigen elimination diets are an effective method to identify EoE allergens and a safe EoE treatment option, but they require prolonged dietary changes and numerous EGDs. These factors have been barriers to broad clinical implementation of dietary EoE treatment. Interestingly, the studies found that esophageal symptoms recurred during food reintroduction. Our objective was to determine if EoE patients can identify their allergen(s) based on symptoms during food antigen dose-concentration challenges. Methods: Prospective, single center, IRB approved study. Eligible patients had EoE as defined by the 2013 ACG guideline. Patients with esophageal dilation within 1 year were excluded and PPI therapy twice daily was maintained throughout the study. Subjects received basic EoE education from a gastroenterologist. They then met with a nutritionist to assess their baseline exposure to the 6 most common EoE antigen food groups. The subjects then performed sequential challenges, consisting of consumption of at least twice their baseline intake of each group for 5 days, followed by 2 day washouts. Any additional food allergens suspected by the subjects were also tested. They then followed up in clinic to identify potential food allergens using food-symptom diaries and were instructed to eliminate suspected food allergens from their diet for 6 weeks. After this elimination period the subjects reported symptomatic changes and underwent an EGD. Esophageal biopsies were evaluated by a gastrointestinal pathologist blinded to the study. EoE EREF scores were compared to baseline results. The primary endpoint was histologic response with secondary endpoints of clinical and endoscopic response. Results: 18 of 21 subjects (86%) completed the study. Per intention to treat analysis 62% achieved histologic response and 76% experienced clinical response (table 1). Histologic remission was reached in 24% of subjects (table 2). Conclusion: Improved methods to identify EoE allergens are needed. This novel method to identify EoE food allergens requires 2 clinic visits, 3 months of patient-directed dietary trials, and 1 EGD. This study demonstrates that sequential, dose-concentration dietary challenges can identify potential EoE food allergens and that histologic and clinical response can be achieved in most EoE patients by eliminating symptom inducing foods.331_A Figure 1. A-FANCSE Results - Intention to Treat Analysis331_B Figure 2. Comparison of rates of subjects achieving histologic remission (defined as <15 eos/hpf) and EoE food allergen identification in elimination diets.331_C Figure 3. A-FANCSE Histologic Response