Dr Dellon reviews a recent update to guidelines for eosinophilic esophagitis, which he presented at the American College of Gastroenterology scientific meeting.

Evan Dellon, MD, is a professor of Medicine and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina.

Hi, I'm Evan Dellon, professor of medicine at University of North Carolina School of Medicine in Chapel Hill, North Carolina. I'm the director of our Center for Esophageal Diseases and Swallowing and I'm an adult gastroenterologist and my main clinical focus is eosinophilic esophagitis and other eosinophilic GI diseases.

We're here at the ACG meeting for this year and I had the privilege of being able to present the new ACG guidelines for EOE. They'll be out in press in January of the coming year and hopefully available online sooner than that. But this was the first time that I was able to discuss these in a public forum.

Now, our last version of these guidelines was back in 2013, and so you could imagine over the previous 10 years we've had a lot of advances, and it was time for our guidelines update. We know a lot more now about the risk factors, natural history and outcomes of the condition. We have a number of validated outcome metrics and a new severity index, and importantly from the patient standpoint and from the provider standpoint, we have 3 treatments that are approved globally, and 2 of these treatments are approved here in the US by the FDA.

The guidelines were developed by a multidisciplinary committee that included pediatric and adult GI docs, allergists, and methodology experts in guideline development. The guidelines span diagnosis and treatment of EoE in addition to long-term maintenance and monitoring. They're also pediatric considerations and so all in all there's 19 recommendations and 25 key concept statements that kind of give a practical twist to the guidelines and give a little bit of color about what to do in practice with the patients.

Now in terms of diagnosis the guidelines are very consistent with the 2018 consensus statement for diagnosis. There are 4 diagnostic recommendations. These mostly put a little more emphasis on how to assess endoscopically your biopsy patterns and reporting out eosinophil counts on the pathology front, but still to diagnose EoE you need the right clinical presentation. You need at least 15 Eos per high-power field on biopsy and you still need to exclude other causes.

Now, in terms of the treatments, we went through and the key treatments, again, are PPI, dietary elimination, and topical steroids as first-line therapies, and now these guidelines add dupilumab as the approved biologic in EoE as well. In general, the PPI, topical steroids, and diet elimination are going to be largely the first-line treatments, and these are still determined with the shared decision-making framework.

We do acknowledge that the budesonite oral suspension is the FDA -approved topical steroid in the US. Now, there are some key changes in the dietary elimination guidelines, where PPIs and topical steroids are still recommended. Now, for the diet elimination, there is an emphasis on selecting an empiric elimination diet first and potentially based on randomized trial data potentially selecting less restrictive elimination diets. So a one-food elimination with dairy elimination only or a 2-food elimination with dairy and wheat elimination to start with, rather than going down the traditional highly restrictive, 6-food elimination approach.

Now in terms of dupilumab, this is a recommended therapy in patient groups that are both 12 years old and above based on the adolescent and adult clinical trial data and in patients 1 year old and above based on the newer trial data in younger children. These are recommended for patients who had not responded to prior PPI therapy as that was the main inclusion criteria in those trials. And in general, it's recommended as step-up therapy for people who aren't responding to those first-line therapies, with some allowances for earlier use in patients with multiple atopic conditions or who are intolerant to PPI or topical steroids.

When we look at the treatment algorithm overall, we have presented a new treatment algorithm in these guidelines. And there's a focus on approaching the anti-inflammatory treatments in parallel with assessing for fibrosis and performing esophageal dilation with a recognition that either one of those in isolation may not get patients the response that they need. And so I think that treatment algorithm is a very nice and practical thing to use from these guidelines.

There's also the emphasis on EoE as a chronic disease that needs monitoring. And monitoring both of initial treatment response and long-term response can't be done with symptoms in isolation. The recommendation is to do this with an assessment of symptoms endoscopic severity and histologic features as well.

And then finally, the pediatric considerations really focus on consideration of esophagram in those younger patients who have trouble swallowing and bringing in feeding therapists or dieticians or nutritionists for the children who are having feeding dysfunction.

When we think about treatment outcomes, we do recommend following symptoms endoscopy and histology for all patients, but in children remembering to focus on growth, development, and nutrition as well.