A Single-Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children

Wechsler, Joshua B.; Schwartz, Sally; Arva, Nicoleta C.; Kim, Kwang Youn; Chen, Liqi; Makhija, Melanie; Amsden, Katie; Keeley, Kaitlin; Mohammed, Saeed; Dellon, Evan S.; Kagalwalla, Amir F.

doi:10.1016/j.cgh.2021.03.049

Cited by 51 publications

(60 citation statements)

References 32 publications

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“…However, no data are available in adults; methodologic issues limit the interpretation of these studies (90). More recent studies have demonstrated histologic remission in .50% of children and a similar efficacy to the 6-food elimination diet (91,92).…”

Section: Review Articlementioning

confidence: 99%

Disease Burden and Unmet Need in Eosinophilic Esophagitis

et al. 2022

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Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease of increasing prevalence, characterized by symptoms of dysphagia and reduced quality of life. A dysregulated type 2 immune response to food and aeroallergen leads to barrier dysfunction, chronic esophageal inflammation, remodeling, and fibrosis. Patients with EoE have impaired quality of life because of dysphagia and other symptoms. They may also suffer social and psychological implications of food-related illness and expensive out-of-pocket costs associated with treatment. Disease burden in EoE is often compounded by the presence of comorbid type 2 inflammatory diseases. Current conventional treatments include elimination diet, proton pump inhibitors, and swallowed topical corticosteroids, as well as esophageal dilation in patients who have developed strictures. These treatments demonstrate variable response rates and may not always provide long-term disease control. There is an unmet need for long-term histologic, endoscopic, and symptomatic disease control; for targeted therapies that can normalize the immune response to triggers, reduce chronic inflammation, and limit or prevent remodeling and fibrosis; and for earlier diagnosis, defined treatment outcomes, and a greater understanding of patient perspectives on treatment. In addition, healthcare professionals need a better understanding of the patient perspective on disease burden, the disconnect between symptoms and disease activity, and the progressive nature of EoE and the need for continuous monitoring and maintenance treatment. In this review, we explore the progression of disease over the patient's lifespan, highlight the patient perspective on disease, and discuss the unmet need for effective long-term treatments.

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Section: Review Articlementioning

confidence: 99%

Disease Burden and Unmet Need in Eosinophilic Esophagitis

et al. 2022

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“…72 The next obvious stage in empirical diet therapy for EoE was a single food elimination diet, namely, a milk-free diet. Most research on this approach overestimated the true effectiveness of this intervention either due to the biased inclusion of patients with a previous IgE-mediated reaction to milk, who overcame it either spontaneously or after oral immunotherapy, 73 or by the recruitment of patients concomitantly treated with proton-pump inhibitors (PPIs), 74,75 a drug that produces anti-inflammatory effects in half of the patients with EoE. 76 The most accurate figures for the efficacy of a milk-free diet in EoE are probably around 44%, as recently demonstrated by a randomized controlled trial (RCT) exclusively reported as an abstract, 77 with further studies being required to confirm these results.…”

Section: Elemental Diets and The Definition Of Eoe As A Food Allergymentioning

confidence: 99%

Evidence-based treatments for eosinophilic esophagitis: insights for the clinician

Feo-Ortega

Lucendo

2022

Therap Adv Gastroenterol

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Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients’ age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.

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“…A six-food elimination diet approach 4,6 was used in 6 patients; 7 patients underwent a four-food elimination diet 8,9 and 3 a two-food elimination diet. 10 Finally, a single-food elimination (or milk-free) diet 28 was used in the remaining 2 patients.…”

Section: Study Design and Participantsmentioning

confidence: 99%

Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk

González‐Cervera

Arias

Navarro

et al. 2022

Aliment Pharmacol Ther

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Summary Background Cow's milk protein is the main food trigger for eosinophilic oesophagitis (EoE) in children and adults and should be continuously avoided once identified as such. Aims To evaluate tolerance of sterilised cow's milk (boiled instead of UHT processing) with regard to maintenance of EoE remission, health‐related quality of life (HRQoL), nutritional intake and allergic sensitisation in patients of all ages with milk‐triggered EoE Methods We prospectively recruited patients in whom cow's milk was demonstrated to trigger EoE after an empirical food elimination diet‐based study. They were given 200 ml of sterilised cow's milk twice daily for 8 weeks. Endoscopic assessment, peak eosinophil counts, oesophageal‐related symptoms, HRQoL, blood eosinophils, eosinophil cationic protein (ECP), skin prick test and serum total and specific immunoglobulin E (IgE) to major milk proteins were monitored before and after sterilised milk intake. Results Eighteen patients (13 male) in EoE remission underwent a sterilised milk challenge. Twelve maintained EoE remission (<15 eos/hpf) while EoE recurred in the remainder. Endoscopic appearances deteriorated in non‐tolerant patients. HRQoL scored well at baseline and was maintained among patients tolerant to sterilised milk, but deteriorated in reactive ones. No significant changes in blood eosinophil count, ECP, tryptase or total and milk‐specific IgE serum levels were observed from baseline. However, cow's milk‐specific IgE increased slightly in non‐tolerant patients. Clinical and histological remission were maintained in patients who regularly consumed sterilised milk for 1 year. Conclusion Sterilised milk did not trigger EoE in two‐thirds of patients with documented milk‐induced EoE, in either the short or long term.

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A Single-Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children

Cited by 51 publications

References 32 publications

Disease Burden and Unmet Need in Eosinophilic Esophagitis

Disease Burden and Unmet Need in Eosinophilic Esophagitis

Evidence-based treatments for eosinophilic esophagitis: insights for the clinician

Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk

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