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Can we predict the course of eosinophilic esophagitis in children?

Published online: June 28, 2019

Eosinophilic esophagitis, known as “EoE,” is a chronic inflammatory disorder of the esophagus that causes symptoms of trouble swallowing, abdominal pain, and vomiting. In some children and adults, EoE can be extremely difficult to treat. While some children respond very well to therapies for EoE including proton pump inhibitors, swallowed steroids, or food elimination diets, others respond intermittently, and some never have complete resolution of the inflammation. In order to best gauge chronic EoE management, it is important to know the clinical differences in patients who do and do not respond to therapy over long time frames. EoE remission is rare and there is a concern of losing control of the disease process when therapy is discontinued. We currently do not know if children who respond to treatment over long time periods could be tried off their EoE-directed therapy and remain disease free.

In a recently published original article in The Journal of Allergy & Clinical Immunology (JACI), Collins, Palmquist and colleagues tracked the course of 146 children with EoE at a single center. On average, the children had 5 years of follow-up and 3 or more endoscopies.  The authors tracked the esophageal eosinophil counts of these patients. Active EoE was defined as 15 or more eosinophils per high power field in the esophagus and response was determined by an average esophageal eosinophil count of less than 15 per high power field. The investigators also collected clinical data including demographics, therapies, symptoms, and allergic sensitizations to foods and environmental triggers.

Over time, the pattern of the children’s’ EoE fell into 3 groups while being treated with swallowed corticosteroids, elimination diets, proton pump inhibitors, or a combination of these therapies. There were children who were “continuous responders” (more 75% of the time with controlled esophageal eosinophils), “intermittent responders” (less than 75 but more than 25% of the time with controlled esophageal eosinophils), and “non-responders” (25% or less of the time with controlled esophageal eosinophils). The investigators found that children of biological female sex were significantly more likely be in the continuous responder category. They also found that a child’s initial response to any therapy aligned with a continued response over time. Children who did not respond to their initial therapy were more often in the intermittent or non-responder groups and were more often male.  There was a higher incidence of nasal allergies in patients in the intermittent responder group, especially in children older than 13 years, but food allergies did not differ between groups. The severity of the findings on endoscopy correlated well with the degree of esophageal eosinophilia. Among the entire group, 13% of the patients were off therapy at the last biopsy and had controlled EoE; 84% of these children were in the continuous responder group.

These findings suggest that children of male sex have an increased risk of persistent eosinophilic inflammation and that if a child responds initially to therapy, he or she will likely continue to respond. Future studies will help determine if those children who respond well initially can eventually tolerate being off their EoE-directed therapy. It also shows the importance of developing additional treatments for children with EoE who do not initially respond well to standard EoE therapy. This study helps us to better understand the trajectory of disease in children with EoE.

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

Graphical Abstract