Perspective from Scott Gabbard, MD
Disclosures: Hirano reports receiving consulting fees and research support from Adare, Allakos, Celgene, Regeneron and Shire. Please the full guidelines for all other authors’ relevant financial disclosures.
April 28, 2020
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AGA issues new guidelines on eosinophilic esophagitis

Perspective from Scott Gabbard, MD
Disclosures: Hirano reports receiving consulting fees and research support from Adare, Allakos, Celgene, Regeneron and Shire. Please the full guidelines for all other authors’ relevant financial disclosures.
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The American Gastroenterological Association published new guidelines focused on the treatment of children and adults with eosinophilic esophagitis.

The AGA partnered with the Joint Task Force for Allergy-Immunology to provide recommendations on management of these patients, including which therapies should be prioritized.

“Over the past two decades, EoE has emerged as a dominant cause of swallowing difficulties worldwide,” Ikuo Hirano, MD, from Northwestern University Feinberg School of Medicine, said in a press release. “The recommendations we’ve outlined will guide allergists and gastroenterologists in effectively managing their patients’ EoE and improving their quality of life. As the field moves forward, a deeper understanding of the natural history of EoE in both children and adults is needed to inform clinical decisions regarding the optimal use of disease monitoring and long-term, maintenance therapy.”

Key highlights of the guideline include:

Topical steroids are recommended as first-line treatment for EoE

For patients with EoE, the AGA recommended topical steroids over no treatment. It is the only strong recommendation given in the new guidelines.

In their review, the guideline authors identified studies that compared treatment with topical fluticasone or budesonide with placebo. In these trials, topical steroids failed to induce histologic remission in about one-third of patients, compared with more than 85% of patients treated with placebo (RR = 0.39; 95% CI, 0.26-0.58). Patients treated with topical steroids also experienced no increased risk for adverse events.

Although no medications have received FDA approval for EoE, they are regularly used in clinical management of the disease and are considered safe for use in patients with asthma.

The guidelines also support topical steroids over oral glucocorticosteroids.

Proton pump inhibitors, diet therapy, esophageal dilation also recommended

While approximately two-thirds of patients with EoE do not respond to PPIs, guideline authors still gave them a conditional recommendation.

“PPIs are positioned as an effective, primary therapeutic option for certain patients with EoE,” they wrote. “Based on their longstanding safety profile and ease of administration, patients may prefer to start with this form of therapy before trials of glucocorticosteroids or elimination diets.”

However, they recommended both an empiric, six-food elimination diet and an allergy testing-based elimination diet over no treatment. In patients with esophageal strictures, authors recommended periodic dilation as necessary in combination with medical and dietary therapies.

More research is needed before targeted biologic therapies can be recommended

Guideline authors wrote that biologic therapies are currently being evaluated, and agents such as anti-interleukin-5, anti-IL-13 and anti-IL-4-receptor-alpha should only be used in the context of a clinical trial. – by Alex Young

Disclosures: Hirano reports receiving consulting fees and research support from Adare, Allakos, Celgene, Regeneron and Shire. Please the full guidelines for all other authors’ relevant financial disclosures.