Optimizing empiric elimination diets for eosinophilic esophagitis in adults

Published Online: September 4, 2014

Eosinophilic esophagitis (EoE) is an emerging allergic disorder predominantly triggered by food allergens. Several dietary interventions have been evaluated in adults so far. Based on amino acid-based formulas, elemental diet is the most effective, but is also impractical, whereas elimination diet based on skin testing has shown suboptimal cure rates (26%-36%). An empiric six-food group elimination diet (SFGED), prospectively evaluated in unicenter studies, has achieved remission in over 70% EoE patients. Still, the majority (65%-85%) of SFGED responders have just one or two causative foods identified after six food-group challenges and endoscopies, so some dietary restrictions and subsequent endoscopies after food challenge may be unnecessary.

Now, in a study recently published in The Journal of Allergy and Clinical Immunology, Javier Molina-Infante and colleagues present the results of the first prospective multicenter study on empiric elimination diet for EoE, evaluating a simplified four-food group elimination diet (FFGED) (dairy products, wheat, egg and legumes) for adult EoE.

The efficacy of this six week FFGED was evaluated in 52 consecutive patients from four Spanish hospitals. In those unresponsive to FFGED, a rescue SFGED was proposed. Among patients responsive to a FFGED, 78% completed the individual food reintroduction process.

The study shows 54% of adult EoE patients achieve clinicohistological remission on an empiric FFGED; in addition, almost a third of non-responders to FFGED could be effectively rescued with a SFGED, coming to an overall effectiveness of 72%. Therefore, 3 out of every 4 adult patients achieving remission on a SFGED may achieve it on a FFGED, a less restrictive dietary intervention that requires fewer endoscopies and shortens the food reintroduction process. After food reintroduction, all FFGED responders had just 1 or 2 food triggers identified. The most common food triggers were cow´s milk (50%), egg  (36%) and wheat  (31%), with milk being the only causative food in 27% of adult patients. Results were consistent among the four participating centers.

This study underscores the general applicability of dietary interventions for adult EoE in clinical practice. This multistage, empiric, dietary approach (FFGED followed by SFGED) may be recommended to simplify dietary management for EoE patients, since a FFGED is a simpler, cheaper and less inconvenient initial dietary intervention to screen a majority of EoE patients with one or two food triggers.

The Journal of Allergy and Clinical Immunology (JACI) is an official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.

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