Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis

Abstract

Background Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disorder that responds to dietary therapy; however, data evaluating the effectiveness of dietary therapeutic strategies is limited. Objective This study compared the effectiveness of three frequently prescribed dietary therapies [elemental, six-food elimination, and skin prick and atopy patch-directed elimination] and assessed the remission predictability of skin tests and their utility in directing dietary planning. Methods A retrospective cohort of proton-pump inhibitor-unresponsive, non-glucocorticoid-treated eosinophilic esophagitis patients who had two consecutive endoscopic biopsies associated with dietary intervention was identified. Biopsy histology and remissions (< 15 eosinophils/high-power field) following dietary therapy and food reintroductions were evaluated. Results Ninety-eight of 513 patients met eligibility criteria. Of these 98, 50% (49), 27% (26), and 23% (23) received elemental, six-food elimination, and directed diets, respectively. Remission occurred in 96%, 81%, and 65% of patients on elemental, six-food elimination, and directed diets, respectively. The odds of post-diet remission vs. non-remission were 5.6-fold higher (P=0.05) on elemental vs. six-food elimination, 12.5-fold higher (P=0.003) on elemental vs. directed, and were not significantly different (P=0.22) on six-food elimination vs. directed diets. Following 116 single-food reintroductions, the negative predictive value of skin testing for remission was 40%–67% (milk 40%, egg 56%, soy 64%, and wheat 67%). Conclusion All three dietary therapies are effective; however, an elemental diet is superior at inducing histologic remission compared with six-food elimination and skin test-directed diets. Notably, an empiric six-food elimination diet is as effective as a skin test-directed diet. The negative predictive values of foods most commonly reintroduced in single-food challenges are not sufficient to support the development of dietary advancement plans solely based on skin tests.

Systematic review of histological remission criteria in eosinophilic esophagitis

“…Approximately 26% (N = 15) of the eligible studies examined remission among EoE patients who received only the diet elimination treatment formula (SFED, FFGED, ELED) compared to other forms of treatment, with the most common definitions falling within 0 to ≤5 eosinophils/hpf 29, 30, 31, 32, 33, 34 or 11 to ≤15 eosinophils/hpf 35, 36, 37, 38, 39, 40. Interestingly, even among the SFED studies (N = 9), five studies defined remission within the range of 0 to ≤5 eosinophils/hpf, 29, 30, 31, 32, 34 and two studies considered histological remission as <15 eosinophils/hpf 38, 41…”

Eosinophilic Esophagitis: A Comprehensive Review

“…As multiple studies have shown, the EoE response is complex and involves cell-mediated as well as IgE components. This manifests itself in the fact that food-specific IgE serum measurements and SPTs are neither sensitive nor specific methods for predicting EoE triggers in adult patients [27,28,82]. Skin Prick Testing and Atopy Patch Testing are also notoriously unreliable.…”

Eosinophilic Esophagitis–More than Two Decades of Progress

“…Elemental diet has also been shown to be superior to elimination diets. In a study comparing elemental diet to elimination diets remission occurred in 96%, 81%, and 65% of patients on elemental diet, 6-food elimination diet, and directed diets, respectively [73]. In a recent meta-analysis involving 1,317 patients from 33 studies effectiveness of elemental diet was seen 90.8% of cases, 6-food elimination diet was 72.1% effective, and allergy test result-directed food elimination was 45.5% effective [74].…”