More Than Half of Patients With EoE Successfully Respond to Dietary Elimination

A sizable majority (69%) of eosinophilic esophagitis (EoE) patients only had one food trigger.

Using the six-food elimination diet (SFED) can identify specific food triggers and be an alternative to medical therapy for adults with eosinophilic esophagitis (EoE), according to a study published in The American Journal of Gastroenterology.

The SFED is a dietary treatment approach for patients with EoE. Patients remove milk, wheat, soy, eggs, tree nuts/peanuts and fish/shellfish, and after remission, food is reintroduced with the goal of identifying a food trigger.

EoE is a type 2 inflammatory disease that is triggered by a high number of eosinophils. Because some foods may trigger a reaction, dietary elimination, along with medical therapy, is part of first-line management of EoE.

“Previous dietary intervention studies have demonstrated the role of food allergens in the pathogenesis of EoE,” the authors explained. “Therefore, dietary elimination has become a standard of care treatment in both pediatric and adult patients with EoE and has been advocated in both the U.S. and European EoE Guidelines.”

They conducted a retrospective clinical case series of 213 adult patients with EoE who were treated with SFED at a single academic institution. Disease activity was assessed at baseline prior to initiating the SFED, and after a minimum of six weeks on the diet, an endoscopy with biopsy was used to confirm response to the diet.

After SFED, patients were classified as either responders (< 15 eosinophils per high-power field [eos/hpf]) or nonresponders (≥ 15 eos/hpf). More than half (62%) of patients had a histologic response after SFED, meaning there was a change in the tissue, and 54% were categorized as responders since they achieved < 15 eos/hpf. The average for responders was 11 eos/hpf compared with 64 eos/hpf for non-responders.

In responders, the Eosinophilic Esophagitis Endoscopic Reference Score (EREFs) improved from 3.6 to 2.4, while the score worsened in non-responders from 3.8 to 4.4. EREFs captures endoscopic features, including edema, rings, exudates, furrows and the presence of stricture and determines the severity of these findings.

More than three-fourths (77%) of responders noted an improvement in dysphagia symptoms, or difficulty in swallowing, after SFED compared with 37% of non-responders.

Eleven of the patients who were nonresponders went through another six-week round of SFED, and 15 of these patients went through the six-week round plus additional food restrictions. Subsequently, 27% of the nonresponders who only went through the six weeks achieved < 15 eos/hpf and 33% of the non-responders who also went through additional food restrictions achieved < 15 eos/hpf.

The researchers did not note any statistically significant differences among responders and nonresponders when it came to the presence of reported atopic history. In fact, 80% of the responders had an atopic history and 81% of the non-responders also had an atopic history. Similarly, 36% for both groups reported two or more atopic conditions.

There was a difference between the groups regarding history of food allergy. While 26% of responders reported a history of food allergy, nearly half (47%) of non-responders reported a history of food allergy.

Overall, 78% of the patients with histologic response underwent food introduction with 69% identifying one food trigger, 24% identifying two triggers and 4% identifying three. Eleven patients successfully reintroduced all foods without any triggers identified, and they were able to maintain remission.

“Further research into understanding the predictors of response with dietary therapy will be critical in advising patients on pursuing this treatment approach,” the authors concluded.