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Abstract

I read with interest the recent submission by Taft and Mutlu regarding the use of vedolizumab for the successful treatment of apparent eosinophilic esophagitis (EoE) in a patient with Crohn’s disease (CD). This communication, along with a recent clinical observation by Nhu et al,1Nhu Q.M. et al.Am J Gastroenterol. 2018; 113: 1261-1263Crossref PubMed Scopus (16) Google Scholar suggests a potential novel addition to our therapies for EoE and, as such, is worthy of further interest. While esophageal eosinophilia can be seen in both gastroesophageal reflux disease and CD, the lack of response to proton pump inhibitors, absence of other signs of active CD at presentation, and apparent improvement of symptoms with dietary allergen elimination make these less likely etiologies for the patient’s esophageal eosinophilia. This patient did not respond to 1 standard therapy for EoE (the 6 Food Elimination Diet), although she apparently was not tried on topical swallowed steroids, and she did not have an endoscopy while treated with systemic steroids, which would also be expected to treat EoE. Given this, her response to vedolizumab as a sole agent would suggest a therapeutic use for EoE in the setting of inflammatory bowel disease. This is an unexpected finding based on the mechanism of action of vedolizumab, which binds to α4β7 integrin on leukocytes (particularly CD4+ memory T cells in the treatment of CD) to prevent adherence to mucosal addressin cell adhesion molecule-1 (MADCAM-1) on endothelial cells and thus prevent tissue infiltration of the gastrointestinal mucosa. While eosinophils also express α4β7 integrin,2Wyant T. et al.J Crohns Colitis. 2016; 10: 1437-1444Crossref PubMed Scopus (129) Google Scholar esophageal endothelial cells do not typically express MADCAM-1, although there is cell-culture evidence that MADCAM-1 expression can be induced in human endothelial cells by exposure to tumor necrosis factor α, interleukin-1β, and lipopolysaccharide.3Rafiee P. et al.Am J Physiol Gastrointest Liver Physiol. 2003; 285: G1277-G1292Crossref PubMed Scopus (33) Google Scholar Given this pattern of MADCAM-1 expression, it was not surprising that although there have been previous reports of treatment success with the use of vedolizumab in eosinophilic gastritis or gastroenteritis,4Kim H.P. et al.Clin Gastoenterol Hepatol. 2018; ([E-pub ahead of print])Google Scholar there have not been previous descriptions of vedolizumab use in EoE (and in fact limited anecdotal experience in our center has been discouraging). In this current reported case, it is interesting to speculate whether the coexistence of CD and EoE in this patient might have rendered her particularly sensitive to the use of vedolizumab to treat her EoE, as increased circulating levels of tumor necrosis factor α driven by her CD might lead to expression of MADCAM-1 in esophageal endothelial cells and make this an active pathway for esophageal eosinophil infiltration. Further investigation of vedolizumab activity in this rare subset of patients with concurrent inflammatory bowel disease and EoE may be warranted based on this report. The Potential Role of Vedolizumab in Concomitant Eosinophilic Esophagitis and Crohn’s DiseaseClinical Gastroenterology and HepatologyVol. 16Issue 11PreviewEosinophilic gastrointestinal disorders are challenging conditions with limited pharmacologic options that may decrease quality of life and increase health care utilization and costs.1 Kim et al2 present very interesting findings for the use of vedolizumab in a small cohort of 5 treatment-refractory patients with eosinophilic gastritis/gastroenteritis, showing clinical and histologic improvements. However, it is unknown if vedolizumab could be effective in esophageal manifestations of eosinophilic disease, such as intractable eosinophilic esophagitis (EoE). Full-Text PDF