Guidelines on the Management of Eosinophilic Oesophagitis in Children and Adults
The British Medical Journal (BMJ):
British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guideline
These joint consensus guidelines from the British adult and paediatric gastroenterology societies utilize the GRADE methodology to make recommendations for the diagnosis and management of eosinophilic oesophagitis (EoE).
Management of Eosinophilic Oesophagitis (EoE):
Diets:
1. After initiation of therapy (dietary or pharmacological treatment), endoscopy with biopsy while on treatment, is recommended to assess response, as symptoms may not always correlate with histological activity.
2. Elimination diets are effective in achieving clinico-histological remission in both adults and paediatric patients with eosinophilic oesophagitis.
3. Six food elimination diet results in higher histological remission rates than two or four food elimination diets, but is associated with lower compliance and an increased number of endoscopies.
4. When undertaking a dietary restriction therapy for eosinophilic oesophagitis, support from an experienced dietitian throughout both the elimination and reintroduction process is strongly recommended.
5. Combining elimination diets with pharmacological treatment is not routinely recommended but can be considered in cases of drug treatment failure.
6. Allergy testing to foods (eg, skin prick, specific IgE and patch testing) is not recommended for choosing the type of dietary restriction therapy for eosinophilic oesophagitis.
7. Exclusive elemental diets have a limited role in eosinophilic oesophagitis, with high efficacy but low compliance rates and should be reserved for patients’ refractory to other treatments.
Pharmacological Treatments:
8. Proton pump inhibitor therapy is effective in inducing histological and clinical remission in patients with eosinophilic oesophagitis.
9. Proton pump inhibitor therapy should be given two times per day for at least 8–12 weeks prior to assessment of histological response, while on treatment.
10. In patients who achieve histological response, proton pump inhibitor therapy appears effective in maintaining remission.
11. Topical steroids are effective for inducing histological and clinical remission in eosinophilic oesophagitis.
12. Clinical and histological relapse is high after withdrawal of topical steroid treatment, and following clinical review, maintenance treatment should be recommended.
13. Novel biologics used in other allergic conditions (such as dupilumab, cendakimab and benralizumab) have shown promise in the treatment of eosinophilic oesophagitis.
Drugs that are not Recommended:
14. Systemic steroids are not recommended in eosinophilic oesophagitis.
15. Immunomodulators (eg, azathioprine, 6-mercaptopurine) are not recommended in the management of eosinophilic oesophagitis.
16. Monoclonal antibody therapies, such as anti-tumour necrosis factor (TNF) and anti-integrin therapies, that are typically used for inflammatory bowel disease are not recommended in the management of eosinophilic oesophagitis.
17. Sodium cromoglycate, montelukast and anti-histamines are not recommended in the management of eosinophilic oesophagitis but may have a role in concomitant atopic disease.
18. If symptoms recur while on treatment, guidelines recommend repeating an endoscopy for assessment and to obtain further histology.
19. Patients with eosinophilic oesophagitis refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist to optimise treatment.
Doctors Liked to Read More
BACKGROUND
Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.
METHODS
The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.
RESULTS
Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.
CONCLUSIONS
These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
Comments
You must login to write comment