Diet Therapy for Eosinophilic Esophagitis
Diet Therapy for Eosinophilic Esophagitis
Presently, swallowed topical steroids are the most widely utilized medical treatments for both children and adults with EoE. The rapidity of response combined with safety, based on their use in asthma and allergic rhinitis, positions topical steroids as an attractive therapy. Many patients, however, voice reluctance to take medications on a chronic basis and concern about the uncertain side-effects of long-term steroid administration. Presently, topical steroids for EoE are being used off-label, as no medical therapies have been approved by the Food and Drug Administration. Adverse side-effects of oropharyngeal and esophageal candidiasis have been reported in 15% of patients treated with swallowed topical steroids but are seldom clinically significant. Although histologic responses to topical steroids have been clearly demonstrated in randomized, controlled trials, dissociation with symptom response has been appreciated. The difficulties in demonstrating a significant reduction in symptoms is multifactorial: high placebo response rates, persistent dysphagia related to esophageal strictures, adaptive eating behaviors and lack of a validated symptom severity instrument. Other major limitations to the use of topical steroids have been the high reported rates of symptom and histologic recurrence following drug cessation. The long-term effectiveness and safety of the maintenance use of topical steroids for EoE are currently being investigated.
In the context of these limitations and uncertainties regarding topical steroids in the therapy of EoE, dietary therapy is an attractive option for many patients. Dietary therapy offers patients a nonpharmacologic alternative to controlling their disease. In a broader context, studies across disciplines have demonstrated the widespread patient use of alternative medicine to many medical conditions, in spite of available conventional therapies. Many patients find the concept of remedying their disease by eliminating a dietary trigger more appealing than taking a drug to counteract the downstream inflammatory response. Furthermore, when discussing the dietary approach, it is important to emphasize that the strict dietary elimination of multiple foods is for a limited period of time. The long-term goal is the identification and long-term elimination of one or a few dietary factors. In addition, the notion by patients that they will 'never' be able to eat an identified trigger food is incorrect. In the absence of associated food-related anaphylaxis, occasional dietary indiscretion is likely not a major concern. Planned deviation from the elimination diet may be managed by intermittent use of short courses of topical steroids. Moreover, as progress is made in the understanding of the pathogenesis of EoE, newer therapeutic options will almost certainly supplant the current management strategies.
As there are no controlled studies comparing dietary therapy with steroid therapy in EoE, the choice of treatment approach is currently individualized. A discussion with the patient should include both the pros and cons of the distinct therapeutic strategies that may include clinical observation in some instances. The dietary approach does require a highly motivated patient (and motivated physician) willing to take the time and money to purchase allergen-free foods. Major lifestyle modification is needed, especially when travelling or dining out. It is important to appreciate that an imposition is placed not only on the patient but also on the patients' families who may have to modify their own eating habits to facilitate meal preparation and avoid cross-contamination. Available resources are an important consideration in the choice of dietary therapy. Formal guidance and supervision by a dietician or allergist regarding food allergens, dietary recommendations and avoidance of nutrient deficiencies is of great importance to success. Internet patient support groups focused on food allergy and eosinophilic gastrointestinal disorders are valuable resources.
When to Use Diet in the Management of Eosinophilic Esophagitis
Presently, swallowed topical steroids are the most widely utilized medical treatments for both children and adults with EoE. The rapidity of response combined with safety, based on their use in asthma and allergic rhinitis, positions topical steroids as an attractive therapy. Many patients, however, voice reluctance to take medications on a chronic basis and concern about the uncertain side-effects of long-term steroid administration. Presently, topical steroids for EoE are being used off-label, as no medical therapies have been approved by the Food and Drug Administration. Adverse side-effects of oropharyngeal and esophageal candidiasis have been reported in 15% of patients treated with swallowed topical steroids but are seldom clinically significant. Although histologic responses to topical steroids have been clearly demonstrated in randomized, controlled trials, dissociation with symptom response has been appreciated. The difficulties in demonstrating a significant reduction in symptoms is multifactorial: high placebo response rates, persistent dysphagia related to esophageal strictures, adaptive eating behaviors and lack of a validated symptom severity instrument. Other major limitations to the use of topical steroids have been the high reported rates of symptom and histologic recurrence following drug cessation. The long-term effectiveness and safety of the maintenance use of topical steroids for EoE are currently being investigated.
In the context of these limitations and uncertainties regarding topical steroids in the therapy of EoE, dietary therapy is an attractive option for many patients. Dietary therapy offers patients a nonpharmacologic alternative to controlling their disease. In a broader context, studies across disciplines have demonstrated the widespread patient use of alternative medicine to many medical conditions, in spite of available conventional therapies. Many patients find the concept of remedying their disease by eliminating a dietary trigger more appealing than taking a drug to counteract the downstream inflammatory response. Furthermore, when discussing the dietary approach, it is important to emphasize that the strict dietary elimination of multiple foods is for a limited period of time. The long-term goal is the identification and long-term elimination of one or a few dietary factors. In addition, the notion by patients that they will 'never' be able to eat an identified trigger food is incorrect. In the absence of associated food-related anaphylaxis, occasional dietary indiscretion is likely not a major concern. Planned deviation from the elimination diet may be managed by intermittent use of short courses of topical steroids. Moreover, as progress is made in the understanding of the pathogenesis of EoE, newer therapeutic options will almost certainly supplant the current management strategies.
As there are no controlled studies comparing dietary therapy with steroid therapy in EoE, the choice of treatment approach is currently individualized. A discussion with the patient should include both the pros and cons of the distinct therapeutic strategies that may include clinical observation in some instances. The dietary approach does require a highly motivated patient (and motivated physician) willing to take the time and money to purchase allergen-free foods. Major lifestyle modification is needed, especially when travelling or dining out. It is important to appreciate that an imposition is placed not only on the patient but also on the patients' families who may have to modify their own eating habits to facilitate meal preparation and avoid cross-contamination. Available resources are an important consideration in the choice of dietary therapy. Formal guidance and supervision by a dietician or allergist regarding food allergens, dietary recommendations and avoidance of nutrient deficiencies is of great importance to success. Internet patient support groups focused on food allergy and eosinophilic gastrointestinal disorders are valuable resources.
Source...