Clinical Outcomes by Treatment Strategy in Eosinophilic Esophagitis

Abstract

Introduction: Eosinophilic esophagitis (EoE) is an increasingly recognized disease in children and adults. EoE likely has a multifactorial etiology with genetic, immunologic and environmental components. Treatment of EoE consists of therapies including proton pump inhibitors (PPIs), swallowed steroids, and food elimination diets. There is heterogeneity in the chronic care of patients as there are no clear guidelines for long-term management. In a group of adult outpatients with chronic EoE, an evaluation of the relative contribution of each of these therapies on symptom control was the aim of this study. Methods: We conducted a retrospective chart review on patients with biopsy-proven EoE who had been seen by an allergist and were referred from gastroenterologists after endoscopic diagnosis. A telephone survey was conducted to determine current symptoms, a history of treatment regimens, and follow-up. A validated patient-response outcome (PRO) instrument and scoring system for EoE (Schoepfer, et al. Development and Validation of a Symptom-Based Activity Index for Adults with Eosinophilic Esophagitis. Gastro 2014;147:1255-66) was utilized. Results: There were 26 patients who had been diagnosed on average 4.4 years prior to data collection (range 1-10, 18 (69%) were male with an average age of 40 (range 23-59). At the time of the survey, 18 were taking a PPI for maintenance, 15 were using swallowed steroids, and 16 were avoiding foods. Patients who were maintained on a PPI were just as likely as those off PPI to remain symptomatic, defined as PRO>0 (OR 0.8, 95% CI 0.15 to 4.2, P=0.8). Similarly, the use of swallowed steroids for maintenance was not associated with symptoms (OR 1.1, 95% CI 0.22 to 5.0, P=0.95). Avoidance of foods due to triggering of symptoms or food allergies also did not correlate with symptoms (OR 3.0, 95% CI 0.56 to 16, P=0.20). While the majority of patients continued follow up with a gastroenterologist (n=17, 65%), very few continued to see an allergist (n=6, 23%). Conclusion: There is no predominant treatment strategy among the three most commonly utilized for the long-term management of adult patients with EoE. In our study, there was similar use of PPI therapy, swallowed steroids, and dietary avoidance, none of which were individually correlated with symptom-free remission. The heterogeneity in treatment plans and lack of correlation with symptoms emphasize the importance of further studies to determine the ideal long-term management plans for patients with EoE.