Eosinophilic esophagitis: update on management and controversiesBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4482 (Published 13 November 2017) Cite this as: BMJ 2017;359:j4482
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Chen JW and Kao JY (1) report as a possible option of eosinophilic esophagitis (EoE) treatment, diet therapy or the use of topical steroids (Figure 5). As the authors report, the choice cannot be based on solid recommendations, given that there are relatively few high-quality randomized controlled trials that have evaluated pharmacological or dietary treatments for EoE.
The recent paper by Cotton CC et al (2) highlights that the literature describing topical corticosteroids and six-food elimination diet consists of small studies with diverse methods and population characteristics. Meta-analysis with meta-regression shows initial histologic and symptomatic response rates of the same order of magnitude for topical corticosteroids and six-food elimination diet, but heterogeneity of study designs prevents direct comparison of modalities (2). In addition, the current literature has not adequately addressed patient-reported outcomes, patient preferences, compliance to the treatment or quality-of-life indices (3).
Some studies in adults demonstrated the efficacy of an elemental diet but underline that it is expensive, not palatable ad associated with market weight loss (3). Pediatric experience on the treatment of EoE with the diets (elemental, target elimination, empiric elimination) is even more limited than adults and is not without risk. In EoE in children the diet should be used only in special situations such as children with multiple food allergies, failure to thrive, or severe disease (4). The common pediatric experience in the management of eosinophilic esophagitis is in favor of the use of steroids which would in our opinion always be preferred as first line treatment. Both topical and systemic corticosteroids are used for initial treatment in active EoE, as well as for maintenance treatment, whereby the type, strength, and dose are determined according to disease severity, availability, and practicability from the patient’s perspective (5).
The urgent need for establishing standard of care for induction and maintenance of remission in EoE continues to be unmet.
1. Chen JW, Kao JY. Eosinophilic esophagitis: update on management and controversies. BMJ. 2017 Nov 13;359:j4482
2. Cotton CC, Eluri S, Wolf WA, Dellon ES. Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression. Dig Dis Sci. 2017 Jun 12. doi: 10.1007/s10620-017-4642-7
3. Imam T, Gupta SK. Topical glucocorticoid vs. diet therapy in eosinophilic esophagitis: the need for better treatment options. Expert Rev Clin Immunol. 2016;12(8):797-9.
4. Papadopoulou A, Koletzko S, Heuschkel R, et al. Management guidelines of eosinophilic esophagitis in childhood. J Pediatr Gastroenterol Nutr 2014;58(1):107-18.
5. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128:3–20
Competing interests: No competing interests