Proton pump inhibitors and dietary elimination diet superior to monotherapy in refractory EoE

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A small retrospective study looked at outcomes in patients with eosinophilic esophagitis (EoE) who responded to solo therapies.

A recently published study found that a combination of proton pump inhibitors (PPIs) and a food elimination diet (DEF) works better than either alone in patients with eosinophilic esophagitis (EoE) that are refractory to monotherapy.

High-dose PPI monotherapy is currently a first-line therapy for inducing remission in EoE, which is defined as having at least 15 eosinophils per high power field (eos/hpf).

Combination therapy is understudied, the researchers said, writing in Gastro Hep Advances; what is known focuses on topical corticosteroids and DEF, not PPIs and DEF.

The current study aimed to answer some questions raised by an earlier study of 64 children, which showed a reduction in eos/hpf with the removal of milk, wheat, soy and eggs from the diet and PPI therapy. There was a greater proportion of patients achieving histological remission with this combination therapy than with PPI monotherapy, but what was not delineated was whether some patients only responded to combination therapy and not monotherapy or if one subset responded to PPI therapy while another subset responded to FED.

This retrospective cohort study identified patients with EoE seen at Tufts Medical Center in Boston, Massachusetts. They did not respond to IPP monotherapy and FED monotherapy, but responded histologically to IPP and FED combination therapy. A review of patient records also identified changes in symptoms.

Of 405 patients with EoE diagnosed between January 2013 and September 2021, 12 patients were included in the analysis. Eight of the 12 were men (66.7%) and 3 were children. Ages ranged from 7 to 53, with a median age of 23.

Of 12 patients, 4 had histologically active EoE during PPI monotherapy, so baseline information was only available for 8 of the 12. Of these 8, all reported symptoms, most with dysphagia. Histological results showed a median maximum number (IQR) of eosinophils of 45 (35.5-50) eos/hpf.

Using PPI monotherapy, different types of dosing regimens were attempted, but for 75% of patients, symptoms persisted after 6 weeks of treatment, including food impaction, heartburn, and abdominal pain.

The results with an elimination diet were similar. The most popular DEF milk and wheat. Symptoms persisted after 6 weeks of restrictive diet.

The median peak eosinophil count was similar after both types of monotherapy: 45.5 eos/hpf after PPI and 47.5 eos/hpf after FED.

After the implementation of polytherapy, 11 of the 12 saw their symptoms disappear.

Comparative analysis of peak eosinophil count showed that patients achieved a median of 4.5 (2.0-6.5) eos/hpf, which was significantly reduced from baseline (median, 45 [35.5-50.0]; Wilcoxon signed rank test, P P P

As recently as 2017, the authors stated that the combination of DEF and pharmacotherapy was discouraged, “due to the potential for additive side effects, negative impacts on quality of life, and confusion between treatment that induces histological remission”.

In light of their findings, the authors stated that “combination therapy should be considered in the treatment algorithm for EoE, especially for patients who fail to achieve histological remission with monotherapy.”

The retrospective nature of the study and the small sample size are among the limitations of their work, they said; they were unable to identify specifics of efficacy since different treatment combinations of PPI and DEF were used. They encouraged further studies, using standardized treatment plans and taking into account the increased patient burden with combination therapy.

Reference

Leung J, Sia T, Miller M, et al. Combination of proton pump inhibitors and a food elimination diet in eosinophilic esophagitis refractory to monotherapy. Gastro Hep Adv. Published online April 14, 2022. doi:10.1016/j.gastha.2022.04.002


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