Yevgenia Pashinsky, MD
So welcome everyone. I will be starting some of the intros while people are trickling in. Tonight’s webinar is a special one. It’s featuring not one, not two, but three expert opinions on the hot topic of the evening, which is eosinophilic esophagitis. My name is Yevgenia Pashinsky. I’m one of the guest urologist at NYGA who will be your host and moderator as a reminder for housekeeping purposes, any questions you guys have?
There will be a Q&A after we’re done with the full session. And please, any questions you have, put them in the Q&A box as opposed to the chat box. That’s the one that I’ll be monitoring and answering questions along the way and saving some of the good stuff for our panelists to tackle at the end. And just to start introducing our team, our first speakers after Steven Naymagon, whom I know since medical school, and I’m very proud to call my partner these days. He’s a Mount Sinai lifer, much like myself and currently an assistant clinical professor. He’s very involved in the fellowship program and routinely wins teacher of the Year also is an expert at the more complex endoscopic procedures, including endoscopic dilation, which are a pertinent topic for today’s talk and today’s medical conditions.
We’re covering our next expert. It’s our own Faith Aronowitz, who is one of our GI dietitians, at NYGA she earned her master’s in nutrition and exercise physiology from Columbia University, where she also completed her dietetic internship. Faith specializes in the convergence of gastrointestinal health, eating disorders and sports nutrition, employing a weight, inclusive and non diet approach to care. In her practice, she has experience working in both inpatient and outpatient behavioral health populations and is a great resource for EOE patients in a very supportive way.
Last but certainly not least is our guest speaker, Dr. Clifford Bassett. He’s the founder and medical director of Allergy and Asthma Care of New York and the author of The New Allergy Solution, as well as dozens of scholarly articles and presentations. He’s a clinical professor of medicine at NYU and on the teaching faculty at Weill Cornell Medical College. He’s featured regularly by national television, radio and print media outlets and obviously not new to the spotlight. Dr. Bassett is an expert in seasonal and indoor allergy, sinusitis, allergic skin disorders and offers a very integrity and whole body approach to allergy prevention and management. He’s also very interested and an expert on EOE. So with that intro, just reminder, guys, Q&A box for questions and I’m going to give it away to my panelists.
Steven Naymagon, MD
Thank you for that very kind introduction, and thank you to my co-hosts today for joining me. And thanks for to everybody in the audience for listening today. So today’s topic is eosinophilic esophagitis. And these are some of the things that we’d like to cover today. We’d like to define eosinophilic esophagitis, which I will sometimes abbreviate as EOE because, saying, Eosinophilic esophagitis over and over again can be a mouthful. We want to review how food allergies leads the development of EOE. We like to explain how a diagnosis of EOE is established. We’ll discuss the treatment options for EOE, and then we’ll differentiate food allergies from food intolerances, which is very pertinent to this topic.
So jumping right into it, how do we define this condition? Well, there are four components. The definition chronic is a chronic disease. It’s immune and antigen mediated. It’s characterized by these cells called eosinophils, and it’s also characterized by certain specific symptoms. So we’ll go through these one by one and I think it’ll make a lot of sense. So is an esophageal disease. So it affects the esophagus, which is the organ that connects your mouth to your stomach. Now, it’s important to point out that the esophagus is not just a food pipe. It’s actually a living, breathing organ. It has muscles and neurons and importantly, immune cells. And if we were to sort of dove down into the surface of the esophagus and look at it very, very closely with an electron microscope, we would see something like this.
We see the lining of the esophagus, which is made of these little hairy looking cells. And just beneath the surface, there are all kinds of immune cells living there and regulating the immune system, and they’re releasing all kinds of molecules that stimulate the esophagus function. So in a condition like EOC, an antigen or a food particle that happens to irritate the esophageal lining, and this particular person stimulates the activity of white blood cells, which then release molecules and and then stimulate the recruitment of another type of white blood cell called an eosinophil. And this cartoon represents the eosinophil. The eosinophil said to travel through the bloodstream and into the lining of the esophagus and cause inflammation.
So if we were to then to look at the surface of the esophageal wall under the microscope a little bit even more closely, we would see this beautiful sea of purple and the sea of purple are normal, normal looking esophageal cells. And then in the sea of purple is his little red and pink dots. And these are the eosinophils. These are those inflammatory cells that are infiltrating the wall of the esophagus, causing inflammation. And when the esophagus is inflamed, it becomes unhappy and it causes symptoms. So that leads to the clinical presentation of EOE, and which is characterized by things like dysphagia, which is another word for trouble swallowing. And sometimes the trouble swallowing can get so bad that you can get a food impaction where the food actually can’t go down through the esophagus. And this could lead to a lot of chest pain. And you can imagine it can be very uncomfortable to have your food stuck in your esophagus. It can also lead to GERD like symptoms or heartburn like symptoms which can be refractory to medications and can last for a very long time. And this is a very important point because this can lead to a misdiagnosis if people assume that they just have acid reflux. But it’s actually something like eosinophilic esophagitis.
Finally, it can also cause a cause abdominal pain. So you can see there’s a whole host of symptoms that can be caused by this esophageal inflammation. Just an important point here is that children can often present differently than adults and kids can have feeding, dysfunction, vomiting, abnormal abdominal pain more commonly than dysphagia and food inpactions that are more common in adults. So, again, it’s an esophageal disease. It’s caused by being in an activation of the immune system by an antigen. It leads to the the flocking of these cells called eosinophils to the surface of the esophagus. And that leads to inflammation and symptoms of this esophageal dysfunction.
So a few words about the epidemiology of EOE. So first of all, this is a relatively new disease and was first described in the 1990s, but now we know a lot more about it, including what causes it. And it has treated importantly, the most common people affected by it are males in their twenties and thirties, but it can affect all comers and the prevalence seems to be steadily increasing.
This is a chart showing the prevalence of EOE and the trends over the past couple of decades all over the world in the U.S., Australia and Europe. You can see that all over the world. The numbers are rising. So this disease is here to stay and it’s going to be more and more common.
So how do we make the diagnosis? How do we establish that somebody has EOE? Well, it hinges on three factors clinical suspicion, endoscopy and histopathology. So clinical suspicion we already talked about. These are the symptoms that should lead someone to think maybe this person has eosinophilic esophagitis, trouble swallowing, food impaction, chest pain, GERD like symptoms that just don’t get better or upper abdominal pain.
Another important point is that EOE often travels together with other allergic conditions, such as food allergies, environmental allergies, asthma, atopic dermatitis. So, for example, if a young man with asthma and atopic dermatitis comes to their doctor complaining that they have trouble swallowing, a light bulb should go off, this person might have eosinophilic esophagitis, and I might want to refer them for an endoscopy, which is the next step in making the diagnosis.
So an endoscopy is a test where a gastroenterologist introduces a small, flexible tube carbon endoscope, a camera on it, down through the mouth, into the esophagus and into the stomach. The procedure is done under sedation so the person doesn’t feel, remember or experienced any part of the procedure. And as the gastroenterologist is looking at the esophagus of the patient, they usually see something like this, a wide open tunnel, this beautiful, pale, smooth lining and these nice blood vessels coursing all around the esophageal lining. So this is a normal esophagus in someone with EOE. We might see something like this. So this is pretty classic.
These are called esophageal rings. And you can imagine it’s first of all, this looks very different from the normal esophagus. And you can imagine that these rings can make it very difficult for food to go down, leading to trouble swallowing and potentially even food impaction. Another common findings in addition to these rings are these little white dots which are actually deposits of eosinophilia on the surface of the esophagus representing inflammation. And finally, you can have these lines running up and down the esophagus, which are called longitudinal furrows, another sign of esophageal inflammation.
So the next step is that the gastroenterologist takes a little forceps and takes a piece of the lining of the esophagus and takes a little biopsy. And this biopsy is sent to a pathologist, and the pathologist looks under the microscope and sees something like this. You’ve all seen this picture before. You are now all experts. You see this, these purple cells which are normal and these little red cells and these are the eosinophils and these cells are abnormal. And the pathologist will literally count the number of eosinophils that he sees, he or she sees on the screen. And if there are more than 15 eosinophilia, that constitutes a diagnosis of eosinophilic esophagitis.
So why do we care? Why is this important? Why? Why do we want to make this diagnosis and make it accurately and swiftly? Well because eosinophilic esophagitis can lead to complications? And we already mentioned that these complications could include a esophageal strictures and food impaction. So a normal esophagus exposed to chronic inflammation can lead to a narrowing of the lumen, the esophagus, such that food cannot go down. And then when you try to eat this delicious looking cheeseburger, it’ll get stuck. And this is a big problem. And esophageal food impaction is actually a medical emergency because this cheeseburger sitting in the esophagus for an extended period of time can actually cause necrosis of the wall of the esophagus or damage to the wall of the esophagus, and in the extreme case, can actually cause a tear or perforation of the side.
So we really want to try to manage this disease and manage it effectively and efficiently so that we do not have things like inpactions and and perforations. And this includes an allergy evaluation, which Dr. Bassett will talk about in more detail and elimination diet, perhaps, which Faith we’ll talk about.
And then, of course, we have medical therapies. And again, the goal of all of these therapies is to decrease esophageal inflammation, thus decreasing or eliminating symptom burden and preventing complications. In terms of medicines, one of the classes of medicines that we often use are proton pump inhibitors. So these are medicines you’ve probably seen in the pharmacy like Prevacid, Prilosec, Nexium.
There are tons of them on the market. They’re all used to treat acid reflux and heartburn most of the time. But because they suppress gastric acid, they decrease the amount of acid your stomach is producing. And that’s that’s their main function. However, you get the added benefit that these medicines also are anti-inflammatory, they have anti-inflammatory properties, and that’s how they help with eosinophilic esophagitis.
An important point is that these medicines are not FDA approved for EOE and so they are used off label. However, they do have a decent response rate. Up to 50% of people with EOE will respond and get better on proton pump inhibitors. The next class of medications that we have for you are topical corticosteroids, and these are anti-inflammatory medicines that are often used for all kinds of different conditions. And unfortunately, there is no topical steroid that is formulated for EOE at the moment. So we, as gastroenterologists and allergists, have to borrow from our pulmonology colleagues and used asthma medications so we can formulate or advise patients how to use their asthma inhalers or other asthma medicines to reach the esophagus instead of the lungs. Now, again, these are not FDA approved for EOE, and so they’re used off label, but they do work pretty well with a response rate of roughly 75%. And now this year, it was a very exciting year for EOE because we now have our first FDA approved treatment for EOE.
It’s a medicine called Dupilumab or Dupixent, which is an immuno modulating medication that Dr. Bassett will discuss in more detail in just a few minutes. And finally, if all else fails and the medications aren’t doing it, there are endoscopic therapies that we can offer in EOE. And that includes esophageal dilation.
So as we mentioned, EOE can cause stricture or narrowing of the lumen of the esophagus, thus preventing food from going down. So as gastroenterologists, what we can do is perform in endoscopy and use various tools to stretch these narrowing sort of these strictures, thereby allowing people to swallow more effectively and prevent food impactions. However, if a food impaction does happen, we can perform food disimpaction where we go in and with all kinds of tools, including this fishing net, and try to drag out any food that’s stuck in the esophagus.
So with that, I’m going to now circle back to faith to talk about dietary management of EOE and then I’ll talk to you guys again during the Q&A.
Faith Aronowitz, MS, RD, CDN
Okay. So there are a couple of different approaches as far as elimination diets for EOE goes. And tonight I’m going to cover the empiric elimination diet, which is what we use in our practice. But there’s also another approach which is a more targeted elimination diet based on various allergy testing, and Dr. Bassett will speak more to this in just a couple of minutes.
So the empiric elimination diet means that the word empiric, rather, means that the foods that are excluded from the diet are based on observation or a clinical hypothesis versus actual testing results or other data. So the six food elimination diet excludes the six foods that are most commonly associated with food allergies. And those six foods are milk, wheat, egg, soy, peanuts and tree nuts and fish and seafood.
And studies which trialed the six food elimination diet in adults with EOE showed very promising results in symptom improvement, while also helping clinicians to identify specific food triggers for these symptoms.
And so there are a range of options available that have developed out of this six food elimination diet. As you can see here on the slide, there’s the four food, the two food and the one food elimination diets as well.
These groupings of specific foods are derived from the current literature, which has shown that milk and wheat are the most common food triggers for adults with EOE, followed by egg, soy, peanuts, tree nuts and fish and seafood. So what does the protocol actually look like for doing one of these elimination diets?
So the first phase is the elimination phase, which is six weeks of strict exclusion of one or more potential food. triggers, right? So that could be one food. If you choose the one food elimination diet, that could be up to six foods. If you’re going with the six food elimination diet. And it’s important to note that there’s no, quote unquote, right way to to make this decision of what you’re going to choose.
Obviously, the six food elimination diet is significantly more restrictive than the one or two food elimination diet. So it’s important for the patient to consider what’s feasible for them given their current lifestyle and resources, as well as, of course, recommendations from their team.
So once that decision is made, the dietician will provide extensive education as far as what foods are permitted on the diet, alternatives for excluded foods, tips for understanding how to read food and supplement labels, and individualized meal and snack suggestions according to their their lifestyle.
So in our practice, we require patients to submit a food log to us for review for the first 7 to 10 days of the diet. And we actually require that two times to ensure that the patient is not accidentally consuming any of the excluded foods. Right. You wouldn’t want to get to a week, four or five of the diet and realize you’ve been consuming that food accidentally the entire time.
Or maybe maybe you’ve been taking some sort of dietary supplement that had the excluded ingredient in it and having to start all over. So that that piece is very, very important. And at the end of the elimination phase, the gastroenterologist repeats the endoscopy to assess if the elimination of these foods was effective in reducing inflammation or the eosinophil count.
And if that’s the case, the patient would then move on to the reintroduction phase in which they’re reintroducing each food one at a time for six weeks. And in between, each reintroduction is a repeat endoscopy generally to determine effectiveness, right? So you’re looking to see if the reintroduction of that food has resulted in recurrence of inflammation and a higher and or higher eosinophilic count.
And there’s really no set order for the reintroduction phase. It’s very much individualized according to each patient’s, you know, clinical picture. Also taking into account what the patient has missed most from their diet, especially if they did go go forward with the six food elimination diet. Maybe they they they’re somebody that really enjoys ice cream. So they’re looking to reintroduce milk first. And finally, the last the last part of the process is the maintenance phase. And in that phase, the identified food trigger or triggers are excluded from the patient’s diet long term. And at that point, we continue working with the patient to ensure overall nutritional adequacy and variety. Right.
So we’re assessing how how long term exclusion of these foods might affect the patient’s nutritional status. So, you know, we’re we’re continuing to work closely with the patient to provide alternate foods that meet those needs and potentially looking at dietary supplements as well. So needless to say, the level of commitment required for this, this protocol is quite significant.
So there’s a few factors to consider that might help a patient to make the decision that’s right for them, whether that’s deciding which elimination diet protocol to move forward with. Right. Maybe one or two or six or deciding whether whether any elimination diet is appropriate for them. So some factors to consider include the patient’s current nutritional status. So, for example, if a patient has poor nutritional status, if they’re malnourished, for example, if they have an active eating disorder, an elimination diet might not be clinically appropriate for them.
The patient also has to consider their current lifestyle, right? Do they have a job that requires them to travel 3 to 4 days of the week? Are they on and off planes, in and out of hotels making kind of consistent meals and snacks difficult? Do they have a special occasion coming up? Do they have a vacation plan that they’ve had planned for two years in advance? You know, all of these things of lifestyle are important considerations and financial, you know, the patient’s access to financial resources.
So accessibility and affordability, for example, of certain meal or snack alternatives. Right. And might this might require the patient to go grocery shopping at a different store or procure foods from from a place that might be more expensive than they used to.
Social support is really important, right? This is very much an. Not an easy undertaking. So having people in your corner to support you through the process is quite important. And last but not least, you know, the understanding that multiple endoscopies are generally part of this process, right?
So endoscopy is don’t require the same prep that colonoscopy is do, but it’s still still a procedure and and something to take into consideration. And with that, I will go ahead and hand things over to Dr. Bassett.
Clifford W. Bassett, MD
So thanks so much for the wonderful introductions. It’s so nice to be with colleagues that really dedicate and enjoy what they do. You can tell by the of the speakers tonight we’re all in the same field, so to speak, that we’re just trying to identify a problem the patient may have.
And in this case, with eosinophilic esophagitis, I’m always amazed that I’ll see people and perhaps they’ve had symptoms no later than ten years. Even longer. They may have had familial tendencies to have food issues. I often will say to them, how many glasses of water do you have with your meal? And they say, Oh, at least two or three. And how long is that going on? Since I was a teenager. So there are a lot of people that may have food related reactions, but they don’t get the relief because they don’t get the diagnosis because they don’t get to the right professionals for this.
So this is what I find. It’s exciting. It’s a collaboration in the allergy community. We’ve been involved with managing food allergies for decades and we look at elimination diets and strategies to reduce risk.
This is a little different. We’ll talk tonight a little bit about the role of EOE. And it’s part of what we call the allergic march. And I have a diagram that talks about different allergic conditions to life and how a EOE comes towards the end of the pattern of different conditions.
On this first slide, you can see the perspectives of an allergist and a gastroenterologist in terms of evaluating, diagnosing and determining whether to do an endoscopy, which will allow them to visualize the esophagus as well as take biopsies and confirm the diagnosis. Steven had mentioned 15% of those for high powered field is a preliminary cutoff for the identification of this condition. Eosinophilic Esophagitis. As an allergist, we deal with the ascent up on a variety of conditions, as well as in asthma.
And one of the new treatments we will mention tonight, which is Dupilumap or Dupixent. It’s also been used for the past many years in allergic asthma, chronic sinusitis, as well as eczema, atopic dermatitis. So it’s exciting to have a potential management tool that is effective in multiple conditions, both allergic conditions, and in this case, a gastroenterology condition.
As you see here, I have some pictures of airborne allergies as well as foods. And again, what inspired me is what I just said as a special interest. I’ve been involved since over ten years now. We’ve had some papers in the literature and I’m always amazed that our first paper said, How many years did it take before you actually got a diagnosis? And this is in terms of discussing with our patients in the office, six years, ten years, we have an average of about 6 to 10 years. And that means they’ve been suffering and suffering to go to restaurants. They’re embarrassed, thinking foods. They have to be careful what they eat. And it’s amazing how they don’t really have the insight. It’s not something that people think about.
And we’re here tonight to educate our patients, but also to educate our colleagues, primary care physicians, emergency room physicians about this unmet need in terms of identifying this condition. And early on, I think that’s a very important observation.
Then move to the next slide and this is talking a little bit about over the last couple of decades, eosinophilic esophagitis has emerged as one of the leading causes of food impaction. And literally that’s getting the food stuck in the food pipe or the esophagus in children. It may be less obvious, as Steve mentioned, they may present with heartburn, chest discomfort or acid reflux. So we see different presenting symptoms in adults and children.
We’re going to talk a little bit now about the differences between a food intolerance. This is not an allergy nor a food allergy versus a true food allergy. And just go with some of the terms and of course, we’ll have questions at the end if anyone still has questions about the differences.
So if food intolerance is much more common and it’s experienced with typical food associated symptoms, but it does not involve the immune system. Typical intolerance symptoms are largely gastrointestinal.
We’ll talk about this a bit now. Gas distension, bloating, changing stool habits. And one may think of irritable bowel syndrome, which is of the lower GI tract. And they have a lot of similar symptoms in people with IBS, which is a very common condition in children and adults in terms of people with those symptoms.
However, now we’re talking about food intolerance. So lactose intolerance is a great prototype to start with. It’s very prevalent this ethnicity, depending on where your family is from, and different genetics in terms of who in the family or who in your lineage will develop certain deficiencies. The symptoms result from lack of milk, enzyme, lactase and thus it does not allow proper digestion of cow milk products leading to discomfort.
Now people may find that they can tolerate certain foods such as, say, parmesan cheese, which is very low in lactose, but cows, milk, mozzarella cheese, ice cream, that could be a big problem. So those are intolerance symptoms and those are very prevalent. And gastroenterologist, when necessary, do have breath tests that they can utilize to characterize confirm those types of symptoms. Again, the food intolerance takes place in the digestive system.
It occurs when you’re unable to properly break down the foods. Simply put, and as you see here, we just mentioned the enzyme deficiencies. We’re saying bloating, gas, abdominal pain and diarrhea and so forth.
Now we move over to the area which I spent most of my day dealing with, is, do you have a food allergy? How do we evaluate it? How do we confirm it? And what’s the difference between a sensitivity and a clinical real world allergy?
So a pediatrician can order a blood test for his pediatric patients and he may say check a variety variety of patients for, say, peanut allergy, does the test and says of the mom or dad, this is a test here. This is a sensitivity analysis. Working together.
What I would see is an opportunity for collaboration. That means the sensitivity exists. But if you don’t have symptoms and you don’t have a real world clinical allergy and many of our tests do displayed through blood tests and tests and so forth, it’s a sensitivity to a food. But unless you’re having real world clinical symptoms, that is not a definition of an allergy. Now, I was involved with a study a couple decades ago and looked at when you ask a consumer in a US household, how likely is it that people in your house and what percentage of people do you think have food allergies? Usually you get a number like 20 to 30%. When you actually looked at it in adults, it’s probably more like 1 to 3%. And in children, because the prevalence of milk allergy in early years, it may be as high as 6% or so.
So food allergies are certainly less common than a food intolerance. And you’ll see here that now we’re using the immune system. That’s how we control how your body defends itself. So if you have an allergy to cows, milk your immune system actually seeing cows milk as an invader with something that’s an attack mode.
But instead of your immune system being smart, it overreacts producing IgE antibodies to specific foods and these antibodies travel to at least chemicals. You’ve heard of histamine, and there’s many other chemicals that are responsible for an allergic reaction.
Unlike an intolerance, again, a food allergy can cause serious or even life threatening reaction. That’s why we’re trained as allergists to mitigate risk. Talk about, anaphylaxis keep people away from the ER and do everything we can also to keep them prepared. And that would be having a very appropriate individual epinephrine auto injector pen.
That is the drug of choice for people with food, anaphylaxis, and even in this case, a small amount of food by eating it, which is the number one way that people have exposure to foods and then food related reactions if they are truly sensitive and then there’s contact tray tables and plane, people might go on the plane if they have family members where there’s a nut allergy and they’ll wipe it down. That’s in frequent pause as well as inhalation of the food.
We’re really talking about ingestion tonight. And this is a fairly general talk. So food allergies, again, an immune response leading to a characteristic array of symptoms, a mild fall allergy, itchiness of the throat and so forth, each expansion of the way in a few minutes all the way to multi organ anaphylaxis. That may involve a variety of different systems respiratory symptoms, wheezing, shortness of breath, coughing, a throat, tightness, larynx, inflammation, feeling like the throat is closing up the mouth and face oral facial swelling, an individual with anaphylaxis often accompanied by urticaria or hives. So these signify immediate type reactions. And you see here that nuts and shellfish. So the first quiz question, we’ll see who gets the score right tonight. What’s the number one food allergy in adults in the US? Is it nuts, peanuts or shellfish? And we’ll come back to that in a little bit.
So type one food allergies usually start within several minutes, up to an hour after a food ingestion and again with a mention. There are skin symptoms, respiratory symptoms. But I can see there we can have abdominal symptoms, vomiting, diarrhea and things that can be confusing. And that’s why having a board certified allergist evaluate your family member and go about your find the right studies to identify risk and whether there is a food hypersensitivity reaction that’s occurring EOE is an immune condition, as Steven said, and it’s associated with food and environmental allergies.
And we know from several studies, including my colleagues study at the University of Pennsylvania, Dr. Jonathan Spergel, we know that in some of the studies you’ve looked at in pediatrics, there were individuals that may have had a predisposition to have more symptoms or the diagnosis was picked up during spring and fall when pollen is higher.
We definitely see a relationship there in terms of the pollen season and the prevalence of diagnosis of EOE. We’re talking about three unique dietary eliminations as part of today’s management of EOE. And Faith just went through that beautifully and explained some of the basics to understand and I thought was really well explained. The elemental formula. We’re really not going to talk about that. That’s essentially an amino acid formula, which is not something we’re going to talk about really at this time. The impairment based diet or the food elimination diet comprises what Faith mentioned to you, 2 and 4 and six foods. And that’s something that individuals you look at me as an allergist and say, you got anything else? I’m just not going to give up dairy. I’m not going to give up cheese. I’m not going to give up wheat and beets and so forth. And that’s sometimes can be a hard sell. Or I have other people that are like, tell me what to do and it’s going to get done.
We know that the data shows that empirically based elimination diets and we choose dietary therapy. Remember, as Steve mentioned, medical therapy includes acid reflux pills such as PBI’s. And now, of course, we have DUPIXENT, which we’ll talk about in a few minutes, which is the world’s first biologic, an FDA sanctioned drug for eosinophilic esophagitis. And finally, we have targeted diet based upon varied allergy tests. And we’ve been going back and forth over the last couple decades, the utility of allergy testing and taking a diet based upon that. And we almost always will add cow’s milk to that diet because of the prevalence of cows milk in Eosinophilic Esophagitis We have a variety of IgE tests.
We have a variety of skin tests and so forth. Now, EOE is highly regarded related to that as analogy. It’s not thought to have a typical type of food allergy, so it doesn’t occur immediately. You’re not going to have someone go to the emergency room for having hives and respiratory symptoms. That’s for the type one food allergy. It appears to be more consistent with a delayed sensitivity that occurs over time. And it may also correlate and many people that have atopic histories or allergic family histories to various foods, as well as pollen and even indoor allergens, when I find it very interesting is the data seems to suggest and we talk about in discussion part we can go back and forth that the longer the eosinophilic esophagitis is untreated and the longer the delay the disease progresses and complications are more likely.
And that’s the key, is to be educated, be aware of what we’re looking for, identify this condition early is possible because there’s so many wonderful things we can do to educate, modify trade. And now we have a new biologic that’s designed in many individuals. That would be another opportunity to control the disease by controlling the ecinephiles.
Again, a little bit about testing or food challenges, immediate food testing. That’s what I do throughout the day to identify patients who may be at greater risk of acute food reactions and airways specifically. One of the other reasons may be if we’re going to reintroduce food back into the diet, we certainly want to have a sense whether there is a true food sensitization or clinical reaction. There are.
The three tests that we use are typically skin prick testing A to B, patch testing is very infrequently used. It’s more of an investigational tool and that is basically fresh food put on your back as much as a patch test would be done for somebody with contact dermatitis, skin allergies such as checking for fragrance metal and other skin allergens and the food since the 48 or 72 hours and of course IgE blood tests which is the going to the lab and measuring antibodies to specific foods.
The data shows it’s a pivotal role of food allergy testing. What is the role of food allergy testing? And at this point in time, most individuals will rely on the empiric diet if we’re talking about dietary therapy because of the data and it does not involve allergy testing. I have many patients that also have a variety of allergic conditions, such as asthma, eczema and things like that. And there may be an overlap. And by understanding where the patient’s coming from, the family history and the overlap, we sometimes can make decisions.
Frequently we will do allergy testing when we suspect a food sensitivity and so forth. But I think it’s one of the tools in our toolkit and we’re learning more about elimination diets versus targeted diet, looking at food, skin tests and other tests in some individuals, whether there is a reason to do those tests.
Testing for allergic sensitivity to environmental allergens. Again, pollen, as you see there, the ragweed. Pollen is a very important tool when evaluating a patient with symptoms of seasonal indoor allergies, asthma and other allergic conditions that travel along with EOE or may travel with EOE.
A strong association Eosinophilic Esophagitis, again with food allergies, asthma and eczema, which is atopic dermatitis. A pattern of newly diagnosed EOE, as I mentioned earlier, may be more likely during peak seasonal pollen time periods and less so during winter time.
Research has also identified between one third and one half of children with seasonal and or allergies and up to 65%. Have been estimated to have an allergic reaction to food. So there are definitely some overlaps, but the key is the right testing for the right reason for the right patient at the right time is the key. It’s not a one test model for every one. It depends.
And there’s a role for different types of tests in terms of identifying certain sensitivities. Now, moving over to the last part, which is just very briefly talking about the FDA has now approved DUPILUMAB, which is a monoclonal antibody, a breakthrough drug, a breakthrough classification for the treatment of eosinophilic esophagitis in adults and children greater than 12 years of age.
Dupilumab also improves swallowing, dysphagia and allowing the food to go down into the esophagus, from the esophagus, into the stomach more easily. And it will decrease the number of eosinophils in the esophagus. As well, as I mentioned, improved symptoms. Now we do see individuals on a blood count or the CBC or a blood count that will have a rise in eosinophils in the blood. And that can be seen in between a third and even two thirds of individuals with eosinophilic esophagitis. That’s another marker.
So the biologic would be indicated for an individual that perhaps has tried dietary therapy, what they’ve tried the inhaled steroids swallow and they didn’t tolerate it. Or perhaps they’ve tried the acid suppressive therapy, which is proton pump inhibitors. And a decision would be made based upon the patient is response to any of these treatments and of course pre-authorization that sometimes it’s necessary with the insurer to get approval for Dupilumab I find in the patients I’ve used in Dupilumab, I’ve seen robust responses and I’m excited to have that as another drug in our toolkit to prevent complications and provide options for people that may have had less successful benefit from some of the other modalities.
We talked about the modalities between dietary therapy, drug therapy and when necessary dilation therapy. Those are going to be things that people try and prescribe by that gastroenterologist and in some cases by their allergist in a collaboration setting. It doesn’t work for everyone. And you will find individuals, as we’ll talk about maybe the next five or 10 minutes of they try one approach and they can stay with it. They just can’t deal with the elimination diets.
But other people may gravitate towards medical management, which is definitely moving in that direction. But as a medical management, it’s often very successful and now we have a biologic that will bring in efficacy safety. From what I understand, reading from all the clinical trials and something new to help individuals who have EOE and have been suffering for a very long time. This is the example of a dupixent that would be administered as a self injector at home, and that’s actually quite convenient and we already do that when it comes to asthma and other conditions.
So that’s the end of my talk. Now I believe we’re going to have an opportunity to have some questions and answers, clarifications and the harder the questions the better. Thank you for allowing me to join with you colleagues tonight on a topic that I think is increasing and something that I think is very important to be aware of.
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Yevgenia Pashinsky, MD
Thank you, everyone. That was an amazing talk with a lot of information. I’ve gotten a couple of interesting questions. I think there’s a little bit of something for everybody. So I think a burning question that sort of came in first was whether untreated EOE can increase the risk of developing esophageal cancer. I think that’s that’s a question for the doctors in the room here.
Steven Naymagon, MD
So as far as I know, there is no evidence linking EOE with esophageal cancer. It is true that other inflammatory conditions in the esophagus, such as untreated severe acid reflux, can lead to conditions such as Barrett’s esophagus, which then can lead to esophageal cancer. This is not something that we’ve seen with EOE. Do you do you agree with that?
Yevgenia Pashinsky, MD
Yeah, completely. I mean, it’s definitely an issue that could be debilitating, could cause a significant amount of complications. But I don’t think there’s been any links whatsoever that we know of of the oncologic variety, which is which is a good thing.
Yevgenia Pashinsky, MD
A question for for Faith would be kind of how feasible is this whole sticking to this long term dietary elimination plan? Have you found success? Any have you found patients to be able to adhere to this long term? Or do you find that people end up going on medication?
Faith Aronowitz, MS, RD
Yeah, it’s a good question. I think it really it really depends on the patient. It certainly is is manageable and possible if the patient has the right resources. And I think a lot of that also has to do with, you know, the patient making the choice of six food, four food, two food, one food, right. Obviously, one food is somewhat easier, but then that can prolong the process, right, of sort of working through all of the potential triggers. So it’s certainly I have seen patients stick to it. So it’s definitely it is it is an option.
Steven Naymagon, MD
I think this is a much more feasible option in pediatrics than in adults. I think if there is a parent controlling what goes into a kid’s mouth and they can really effectively use the diet.
Yevgenia Pashinsky, MD
I don’t know about your doctor Naymagon, that all really depends on the age of such child, because I could control at home all I want but goes out the window. So I mean, obviously you have to have, you know, compliant, compliant patients, whether they’re children or adults.
Steven Naymagon, MD
Yes. Yeah. I think that drives home the point. So yeah.
Yevgenia Pashinsky, MD
I think a question for the doctors is among all the different treatments, you know, the medical variety of medications, what are the side effects to such treatments? And sort of is this a long term, forever I have to be on medicine situation or is there a chance that I could one day stop these medications and be okay?
Steven Naymagon, MD
So in terms of the the treatments, so PPIs or proton pump inhibitors, the acid blockers that we use for for most commonly for heartburn, they’re exceedingly safe medications as a whole. I mean, I can walk into CVS and buy a truckload of Nexium and no one is going to say a word and that speaks to their safety. They’re available over the counter. Having said that, there’s no free lunch in this world and any medicine can have some long term side effects. And some issues that have been that have come up with PPIs include issues with absorption of certain micronutrients, perhaps increased risk of certain infections. There’s also been implications of PPI’s causing problems with the kidneys and and the list goes on. But again, these are exceedingly rare side effects in terms of steroids. So steroids are immunosuppressive. So there is a risk for certain infections. The most common infection that we see in people who are using inhaled or I should say swallowed steroids for EOE, is fungal infections of the mouth or oral thrush? It’s pretty uncommon if the medicine is used properly and it’s easily treated if it does occur. Other infections are, I think, are fairly, fairly unusual since this is a low dose topical treatment. Maybe I’ll ask Cliff to comment on his experience with side effects for with dupixent.
Clifford W. Bassett, MD
It’s really well tolerated and what’s nice about it is it’s cross platform. So in dermatology, we’ve been using it and dermatologists around the world have been using it significantly. Game changer, so to speak. And then, of course, we have other biologics that are involved with clinical trials are moving along. Nothing I know of in terms of anything imminent. So we don’t know until it’s announced. That’s the way it works. But certainly we’re going to see some other players in that field that we use in terms of bringing down the eosinophilic counts and so forth. I’d say that it’s really exciting when I have a patient with chronic sinusitis or they have polyps and they have a week where they have eosinophilic asthma and they have a week in terms of hitting it with one gun, so to speak. And you’ve got two different conditions that are treated successfully and complementary. So I think that’s really exciting. The ad home is very attractive to people. They can learn how to do it just in a few minutes. There’s all kinds of people that will come to your house and training. So I think that biologics is certainly going to stay. Certainly in gastroenterology, it’s a huge part of people that practice inflammatory bowel disease and see those patients and so forth. So I think it’s a very convenient none of these are what we call cure. They’re all involved in treating. And in many cases, when we stop a certain modality, whether it be dietary medication, there are times where it appears there is a resolution. The eosinophils go back to normal, the symptoms go away and in some patients, not the majority. I would say because it is a chronic condition, they may see periods of time where they don’t have activities. So that’s not something we can predict. But we do see a variety of responses to all of these. And of course people have opinions and some people don’t really like cutting it back, any food group that they love and other people wouldn’t mind using an asthma pump, but now they’re swallowing it instead of inhaling it. So I think a lot of this is preference and I think guidance and education, there’s no substitute, which is why this program is so unique. It’s complementary between two specialties. And I think that that’s the first step in excellent care is is explaining the condition, what’s happening and giving our patients all the information they can utilize to make the right decisions and move forward with hopefully a condition that up until in the last couple decades was less common and now it’s becoming much more prevalent. I’m writing an article for one of the journals about that, and if you look at some of the instance of EOE in some studies, they think it may be as high as one in every 2000 individuals, which to me sounds just really utterly surprising. So it is on the rise is some talk in the literature about relationship with rising pollen counts in the world, this global climate change and the parallel between this condition. I missed my slides somehow. The one which starts out atopic dermatitis, eczema, asthma for young people, food allergies, those into seasonal indoor allergies. And then at 20 and thirties, low and behold, eosinophilic esophagitis. And we have a lot of questionnaires. Sometimes we’ll give a our patients which will give us a little bit more guidance, particularly maybe a primary care doctor. That’s something we can work with on a different level and find identify people that are at risk, who may be on reflux medications and not really getting the diagnosis diagnosis locked down. Again, as Steve mentioned, complications are not ideal and we do our very best to educate and let people know about symptoms like dysphagia, food, dysphagia, and how something like that can prove dangerous going forward.
Yevgenia Pashinsky, MD
Excellent. So another that this has been, you know, taking you right into another question for Cliff. A lot of excitement on that chat about the whole pollen situation because I feel like some people are hearing for the first time that pollen can sort of be a trigger. And the question lies around whether taking antihistamines or typical allergy meds would help with this somehow or prevent some of the seasonal, you know, flare ups of pollen related flare ups. You know, again, taking, you know, whether it be Zyrtec or, you know, Singulair or some of some of the things that are used for typical allergy symptoms.
Clifford W. Bassett, MD
So there’s an association with a variety of conditions we’ve talked about. Right now we’re going fall into winter. I’m not feeling very seasonal, but there’s a seasonality to that. And in the beginning, one of my first papers or second papers, one was the timeliness, how many years it takes to diagnose EOE. But we looked at what time of the year and we did see a peak in the spring, particularly during the pollen season is definitely an overlap. There’s a few studies, they’re very small looking at allergy immunotherapy, which are actually allergy injections that we use for patients who have allergic symptoms, seasonal, indoor asthma and so forth, and some studies that show some improvement in EOE. But these are not big powered studies and it’s very difficult to say in general, in our allergic individual, we educate them about the pollen count in season and pre Medicaid or pre strategies before the season kicks in. We can do an amazing job before the season kicks in if they start to use their medications. So there’s definitely an overlap between the season. I know some colleagues and I read some review articles talking about using nasal steroids in the spring before the endoscopy and the biopsy, and that may have an impact on the number Eosinophils versus a biopsy that might be done in the winter time when the pollen season doesn’t exist. So I think there’s a lot of questions, a lot of ideas, but I think we’re always learning and this condition is certainly something that is faced with a lot of challenges. And I think we’re mastering it to a certain extent than we could have ever imagined just maybe 20 or 30 years ago.
Yevgenia Pashinsky, MD
Great. And that question for doctor Naymagon, what are the risks of having esophageal deletion? Kind of what what if somebody has a stricture at the time of diagnosis, has impactions and needs one? What is there to be expected?
Steven Naymagon, MD
Yeah, so that’s a great question. And this is there’s been some controversy about this over the past few decades since EOE has become more prevalent. And I think the short answer is that deletions are generally safe in people with eosinophilic esophagitis. The initially we were worried that in inflamed esophagus, doing a dilation can actually cause a perforation. But in a controlled setting where the dilation is done in a safe and serial manner of up to a a reasonable size, meaning you don’t have to blow the thing open. You just have to make it large enough for the person to be able to swallow comfortably. Dilation can become can be done very, very safely. So I think that if a patient has a stricture and requires a dilation, they should not hesitate as they have having it done.
Yevgenia Pashinsky, MD
One more for Dr. Bassett and Faith a little bit is beyond that six food elimination group and sort of the common allergens. Has there been any research looking at any other additional foods or any other food triggers? You know, is there looking to be an individual approach for patients or are we kind of set with the the six food groups?
Clifford W. Bassett, MD
Well, I think that’s a great question. I know if you look around the world, there’s many different research is studying pediatrics and adult medicine, EOE, you can see legumes, meats, chicken and a variety of other things are included. And there’s a conversation about different age groups and what is really important. So I think there is some discussion, but I do think it’s amazing how that empiric diet on it’s just two or six foods seems to be the gold standard and seems to be holding up different sides of the world. They may have a more Mediterranean diet. They may use more foods, lentils, chickpea, sesame. So there are different things in different parts of the world, and they may actually go ahead and try and modify some of the elimination diets and also diagnostic testing. I think diagnostic testing, it definitely has a role in it. It’s less certain than it would be in somebody presenting with a typical food media type reaction. Again, we’re talking about maybe the T cell mediated for the most part, delay mediated foods types of sensitivities. So it is it is different. And I think that we’re learning more about it. And I think that that’s a great question. I don’t know, Faith, have you have any questions about they like to sort of maybe say, well, this food here, I feel there’s something there which is maybe anecdotal, but there are there is room for modification. The only thing is how many foods they can really avoid in the real world and do it for 6 to 8 weeks. And if they have to have an endoscopy and another evaluation, this can go on for a period of time, which can be very challenging for. Individual.
Clifford W. Bassett, MD
Right? Yeah. There’s certainly sort of a diminishing returns, right? There’s only so many so many foods that one can exclude at a time. But those yeah. So those six foods are the most common triggers, but each patient can certainly have their own kind of unique set of triggers. And I think, as Dr. Bassett said, we’re continuing to learn more about about what those could be.
Yevgenia Pashinsky, MD
Excellent. And then I think there is the question about, you know, having repeat endoscopies over and over and over. You know, it’s a lot of work. It’s obviously financially problematic for some patients. It’s this time off of work. Are there any kind of more innovative, noninvasive monitoring strategies that are in the works or that we have available at this point?
Steven Naymagon, MD
So there is there is something that’s either in the works or might be available in some places. Now there’s something called a Cytosponge where which is basically a little, little dissolvable capsule that’s attached to a string. You swallow the capsule and then the capsule dissolves in your stomach. And because it’s attached to a string, the string is coming out of your mouth. I know this sounds very, very appealing. Yeah. So this little string back so that the sponge that comes out of the capsule scrapes off the lining of the esophagus, and then we pull it out and send it to the laboratory, and they can actually count the number of eosinophils. So this is something that is might be available at some very specialized centers, but I don’t think it’s ready for primetime in in the real world quite yet. There are also some places that do unsedated endoscopy so that, you know, it’s just to some degree that at least decreases the, you know, the need for recovery after anesthesia. And perhaps someone can come in, get their endoscopy and just go back to work. So, yeah, there are definitely things on the horizon that could make this easier.
Yevgenia Pashinsky, MD
Excellent. Guys, I think I think we covered a lot of questions. I think if anybody has any particular questions for us, feel free to reach out via our portal. This talk has been recorded so it will be available on our website and on YouTube in the coming weeks. For anybody who may have come late or has any family members or friends that could use a little bit of this talk, I want to thank my amazing panelists here, Dr. Naymagon, Dr. Bassett and Faith for contributing their expertize. And we wish you all a good night.