LAUSR

Eosinophilic esophagitis (EoE) is an inflammatory esophageal disease triggered by ingestion of food allergens, resulting in symptoms such as heartburn, abdominal pain, nausea, vomiting, and dysphagia. Symptomatic, endoscopic, and histologic remission is achieved after treatment with either topical steroids or dietary elimination of the top 4 or 6 most causative foods (cow’s milk, egg, soy, wheat, nuts, and seafood) [1]. There has been limited study of the efficacy of the combination of these two approaches [2]. Moreover, there are many questions and controversies regarding a combination therapeutic approach. Questions surrounding practical management of EoE in the office setting are several. Does treatment with topical steroids at the time of diagnosis hasten symptomatic improvement while patients establish a new diet? Does the dose of topical steroid or the number of food avoidances affect the speed of remission? Can these two therapies combined induce remission faster than single therapy? Are alternating therapies or therapeutic “holidays” valid approaches to therapy? In this issue of Digestive Diseases and Sciences, Reed et al. [3] report on the results of a retrospective cohort study designed to determine efficacy and compliance in pediatric EoE patients receiving sequential treatment with a combination of topical steroids and a 2 food elimination diet (2FED) of cow’s milk and soy followed by treatment with 2FED alone. Each therapy was administered for 3 months followed by biopsy. The combined approach resulted in symptomatic, endoscopic, and histologic improvement. When steroid treatment was discontinued, eosinophilic inflammation reoccurred, although symptomatic and endoscopic improvements persisted through the final clinical and endoscopic evaluations. Strengths of this study include the novelty of the approach (2FED of cow’s milk and soy simultaneously with budesonide) and the comprehensive assessment, including preand post-treatment weights. A report from the same institution documented the relationship between decreased body mass index and EoE diagnosis [4]. Anecdotally, clinicians observe patients treated with dietary elimination who do not consume as many calories after diet initiation compared to before initiation of the diet therapy. These patients continue to have poor weight gain. Reed et al. do not report a significant weight loss with 3 months of 2FED therapy, which is particularly reassuring in patients who initially have a low body mass index, since there is a concern for further weight loss with diet elimination [3]. The “elephant in the room” in most studies of diet elimination therapy in EoE is the lack of assessment of patient compliance to therapy. Obviously, this is a major confounder since it is well known that some patients have inflammatory disease triggered by even trace amounts of allergenic food exposure. This study addresses this issue, documenting compliance in approximately three-fourths of the patients through parental report and physician documentation of compliance in the medical record. It is commendable for the authors to address this, even though parental reporting is frequently inaccurate. Superior methods of compliance assessment are needed in future studies, as it is an important aspect of dietary elimination therapy. Retrospective noncompliance was associated with increased dysphagia and a statistical trend for increased post-treatment eosinophil counts/high powered field (hpf). More studies should attempt to assess compliance to therapy in order to validate the reported results, especially if years have passed since therapy initiation. It is interesting that there were no significant differences between responders to combination therapy in the partial/ complete compliance groups compared to the inadequate compliance group, even though the treatment effect trended toward less response with inadequate compliance. This trend supports the hypothesis that patients who are less adherent to dietary restriction should be treated with corticosteroids. * Carla M. Davis [email protected]