IgE antibodies and response to cow's milk elimination diet in pediatric eosinophilic esophagitis

Abstract

Summary Milk is a common cause of eosinophilic esophagitis. Allergy testing does not predict response to dietary therapy. In this study, patients with low or undetectable IgE antibodies to milk achieved histologic remission with milk elimination.

The Developmental History of IgE and IgG4 Antibodies in Relation to Atopy, Eosinophilic Esophagitis, and the Modified TH2 Response

“…By contrast, assays of IgE to Bos d 4, Bos d 5, and Bos d 8 using immunoCAP gave positive results in ~40 % of the sera [30]. We have recently reported that patients with low or very low titers of IgE to milk can respond well to milk protein avoidance [31]. The argument has changed with recent evidence that these subjects often have high or very high titer IgG4 ab levels to the same cow's milk proteins [32].…”

Using Serum IgE Antibodies to Predict Esophageal Eosinophilia in Children

“…A screening test to identify patients who may need esophageal biopsy would be helpful due to the heterogeneous nature of the symptoms and the increase in esophageal strictures associated with delays in treatment of eosinophilic inflammation (9,10). Levels of IgE antibodies are a common finding in EoE patients, and we have recently proposed that they may be a marker of causal foods and have some utility in planning dietary treatment (18,20). The current study suggests a new role for serum analysis for IgE antibodies.…”

“…These patients would be classified as false positives, and they would lower the specificity of the model. Due to similar clinical, endoscopic and genetic features as well as recent case series suggesting that individual patients can be responsive to both PPI and other dietary and medical treatments for EoE; it has been proposed that PPI simply be considered as a treatment option for esophageal eosinophilia (20,38). It is not yet clear, how this proposal will be incorporated into clinical practice.…”

“…The role of IgE and IgG4 antibodies in EoE is not yet clear. We have recently observed that patients with very low or undetectable IgE antibodies to milk can respond to treatment with cow's milk elimination diet (20). Taken with evidence that EoE does not respond to treatment with anti-IgE, our previous results suggest that IgE antibodies are a marker of an inflammatory response to food but not the cause of the disease process (18,19).…”

Eosinophilic Esophagitis From an Allergy Perspective: How to Optimally Pursue Allergy Testing & Dietary Modification in the Adult Population

“…Similarly, a recent study comparing empiric cow’s milk elimination to swallowed fluticasone demonstrated clinical and histologic improvement in 64 % of children, though this study was limited by the fact that all patients were treated with a PPI [78]. Interestingly, individuals with confirmed cow’s milk-mediated EoE have been shown to tolerate cow’s milk-based hydrolyzed formula [79] and baked milk [80], and recent studies indicate that children who have histologic improvement with milk elimination have lower levels of IgE to milk than those who did not respond (0.50 versus 2.6 IU/mL, p = 0.002) [81]. These findings may improve adherence and nutritional intake in these patients and raise further questions about the underlying pathophysiology of this disease.…”