Eosinophilic Esophagitis (EoE) is a chronic immune-mediated disorder of the esophagus that affects both children and adults. The condition is characterized by inflammation and the presence of a high number of eosinophils in the esophageal tissue. EoE symptoms include difficulty swallowing, food impaction, heartburn, and chest pain. Although avoidance of specific foods is the mainstay of EoE management, other therapies such as oral immunotherapy (OIT) have gained interest as a potential option. OIT is a process whereby patients consume small doses of allergen, gradually increasing to a maintenance dose, to develop desensitization to the allergen. However, some patients experience side effects or do not tolerate OIT. Pharmacological interventions, such as proton pump inhibitors and corticosteroids, have been shown to allow some EoE patients to continue OIT with a reduced risk of side effects. This article will provide an overview of the pharmacological interventions that can help manage EoE symptoms and enable patients to continue oral immunotherapy.
A recent study published in The Journal of Allergy and Clinical Immunology: In Practice found that most patients who developed eosinophilic esophagitis (EoE) during oral immunotherapy (OIT) experienced resolution in their symptoms without stopping OIT. Researchers reviewed the charts of 1,994 patients with proven IgE-mediated food allergy who received OIT between April 2010 and May 2021 and found 13 patients who developed EoE after OIT treatment. For most patients, EoE symptoms developed in the late stages of OIT, commonly after reaching the maintenance dose, some even several years after. Symptoms included abdominal pain, dysphagia, nausea, vomiting, dyspepsia, and chest pain. Once these patients were diagnosed with EoE, 12 of them continued consuming their allergen per OIT protocol, with pharmacological treatment, mostly proton pump inhibitors, added. “Most patients were managed solely by pharmacological treatment, mostly proton pump inhibitors, without stopping OIT. Their outcome was good,” Na’ama Epstein-Rigbi, MD, Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, said. After treatment, all the patients had an esophagogastroduodenoscopy (EGD), with normal macroscopic findings for the full cohort. Six of the 11 patients treated pharmacologically had complete clinical and histological resolution, whereas five achieved full clinical but only partial histologic resolution. Overall, 10 of the 13 patients in the cohort continued their OIT treatment. The researchers noted that there is no consensus definition for nonimmediate gastrointestinal reactions among patients on OIT and that OIT might not be the cause of eosinophilic infiltration. With joint management with gastroenterologists, the researchers said, patients who develop symptoms in OIT-associated EoE can be treated pharmacologically while considering whether they will continue with OIT, although they add that OIT cessation should be considered once pharmacological treatment fails.
In conclusion, pharmacological interventions have shown promise in allowing patients with EoE to continue oral immunotherapy. By reducing inflammation and providing relief from symptoms, medications such as proton pump inhibitors, topical steroids, and biologics can help patients successfully complete OIT without disruption. This is significant progress in the management of EoE, as the ability to tolerate allergenic triggers through OIT offers a potential cure for this chronic condition. While further research is needed to fully understand the optimal use of pharmacological interventions in EoE and OIT, the possibilities for improved patient outcomes are promising.
