Research by a team that includes two faculty members from the University of Colorado School of Medicine may change the treatment paradigm for patients with eosinophilic esophagitis (EoE), an allergic condition that causes chronic inflammation in the esophagus that can lead to esophageal narrowing and dysfunction.
Glenn Furuta, MD, professor of pediatric gastroenterology, hepatology, and nutrition, and Paul Menard-Katcher, MD, associate professor of gastroenterology, helped lead the National Institutes of Health (NIH)-funded, multisite study that shows that a single-food elimination diet — one in which dairy products are eliminated — is just as effective as the standard six-food elimination diet for achieving remission in eosinophilic esophagitis. The paper was published today in Lancet Gastroenterology and Hepatology.
“Eosinophilic esophagitis is a chronic disease that affects children and adults,” Furuta says. “It causes significant problems with eating dysfunction in young children, and in adults it causes problems with food getting stuck and food impactions, as well as problems with swallowing. EoE is classically thought of as an allergic disease sparked by food allergens, so there’s a lot of interest in trying to remove foods from the diet to treat it.”
The problem with that approach, Furuta says, is that there is no test to easily identify which food allergen causes EoE in any given patient. Gastroenterologists typically start treatment by removing the six most common food allergens — dairy, wheat, eggs, soy, fish/shellfish, and peanuts/tree nuts — then reintroducing them one by one to see which sparks the inflammation. It’s an approach that necessitates multiple endoscopies to pinpoint the precise cause of EoE, and one that presents a significant decrease in quality of life for patients who must severely limit their diet in addition to undergoing a series of invasive tests.
Working with the Consortium of Eosinophilic Gastrointestinal eosinophiLic disease Researchers (CEGIR) led jointly by the CU School of Medicine and Cincinnati Children’s Hospital Medical Center, Furuta and Menard-Katcher began looking for a less-drastic dietary treatment option for EoE. Knowing that dairy is the most common allergen responsible for the disease, they constructed a clinical trial for adults ages 18 to 60 with active EoE. Half of the participants were assigned the standard six-food elimination diet for six weeks, and half eliminated only dairy products over the same timeframe.
At the end of the almost three-year trial, the researchers discovered that histological remission was statistically the same in both groups. Thirty-four percent of participants had remission from eliminating dairy alone, indicating that method as an acceptable initial dietary therapy for EoE.
“We started off by saying, ‘Do we have to have so many foods eliminated? Is it necessary to go all the way to removing the six foods, or can we just start with the most common allergen first, and then if that’s not effective, move up to the six-food elimination diet?’” says Furuta, who is working with other CEGIR researchers on a similar study in pediatric EoE patients. “It was taking a very practical approach to addressing a very concerning problem.”
Other treatments for EOE include proton pump inhibitors, topical steroids, and expensive biologic medications, all of which come with side effects. Dietary therapy is preferred, Menard-Katcher says, but eliminating six foods can be intimidating, especially for children. Working with patient-advocacy groups as well as the NIH, the researchers strived to create a patient-friendly trial that would result in an easier path toward remission for more patients.
“We have a lot of patients who would love to do dietary therapy, if that enables them to avoid the use of chronic medications,” Menard-Katcher says. “But the six-food elimination diet has a lot of drawbacks. You’re talking about eliminating a lot of foods that people eat really commonly. Then you add to that the burden of repeated endoscopies to try and identify the trigger or triggers, knowing that you also might not identify those triggers. It’s much easier for a patient to hear that they might have to try eliminating dairy as a first-line therapy rather than dairy, wheat, eggs, soy, tree nuts, and seafood.”
The new study not only is a boon for patients with EoE and the physicians who treat them; it’s also evidence of the strengths in research and treatment for EoE and similar gastrointestinal diseases on the CU Anschutz Medical Campus. That includes the Gastrointestinal Eosinophilic Diseases Program at Children’s Hospital Colorado, a multidisciplinary program that currently sees patients from around 40 states who travel to the clinic for research studies and multidisciplinary care.
“We feel very fortunate because just across campus, Dr. Menard-Katcher and his team are there on the adult side for us to transition our local patients to,” says Furuta, director of the Gastrointestinal Eosinophilic Diseases Program and section head of the Digestive Health Institute at Children’s Colorado. “Institutionally, on this campus, we have a fantastic team that is helping to shape the field.”
Linda Bernstein, Pharm.D.Peer