Combination Therapy Benefits Patients With Eosinophilic Esophagitis Refractory to Monotherapy

Patients whose eosinophilic esophagitis (EoE) was refractory to monotherapy saw improvements in symptoms and eosinophil counts after being treated with a combination of proton-pump inhibitors (PPIs) and a food elimination diet. Researchers published their findings in Gastro Hep Advances.

“[EoE] is a chronic, allergen-mediated disease that is characterized by esophageal inflammation with mucosal eosinophilia,” investigators said. “In some cases, monotherapy may not be able to induce histologic remission of EoE. Therefore, combination therapy, which still remains understudied, must be considered for a next line of treatment.”

For the retrospective cohort study, researchers identified 405 patients with the ICD-10 code for EoE who received treatment at a single academic center between January 2013 and September 2021. Of these, 12 participants had refractory EoE after treatment with PPI or a food elimination diet, but showed a histological response to a combination of both treatments. 

Most patients (87.5%) included in the study presented with dysphagia, and findings revealed 75% of patients were still symptomatic after 6 weeks of adherence to a PPI (most commonly omeprazole 40 mg twice daily) or a food elimination diet (most commonly a 2-food, milk and wheat elimination diet). 

After beginning combination therapy with a PPI and food elimination diet, however, EoE symptoms resolved in 91.67% of patients, with only 1 still reporting dysphagia and 2 reporting continued acid reflux. Patients followed a variety of diets and PPI dosing schedules, but the most common combination treatment involved omeprazole 40 mg twice daily plus a milk food elimination diet (25%).

Additionally, the median peak eosinophil count for patients on combination therapy was 4.5 eos/hpf (IQR 2-6.5). Authors noted this number was significantly lower when compared with baseline (median, 45; IQR, 35.5–50; Wilcoxon signed-rank test, P<.001), PPI monotherapy (median, 41; IQR, 26–50; Wilcoxon signed-rank test, P<.001), and food elimination diet monotherapy (median, 45; IQR, 17–67.5; Wilcoxon signed-rank test, P<.001).

“We highlight that combination therapy should be considered in the treatment algorithm for EoE, especially for patients that fail to achieve histologic remission with monotherapy,” study authors concluded. “Further research investigating the risks and benefits associated with combination therapy for EoE may provide more information on whether a patient should consider it.”

Reference:
Leung J, Sia T, Miller M, et al. Combination of proton pump inhibitors and food elimination diet for eosinophilic esophagitis refractory to monotherapy. Gastro Hep Advances. 2022;1(4):596-600. doi:10.1016/j.gastha.2022.04.002