Eosinophil esophagitis (EoE) is becoming a more widely recognized disease among allergists and gastroenterologists. However, treatment and management of this disease remain controversial among members of the medical community. What doctors do know is that allergies are playing a role in EoE, and pinpointing the exact cause can be difficult.
As far back as the 1960s, eosinophils were seen in the esophagus, but there was no connection to a disease. “By 1995, there was a connection in infants that EoE might be a food-related process. Fast forward to the 2000s, and the recommendations for people with bad reflux changed. They had to have a biopsy for cancers and other screenings. Eosinophils in the esophagus were found in these patients,” says Weily Soong, MD, of Alabama Allergy & Asthma Center. “The prevalence of EoE is increasing now, because we are doing the right tests to catch them. It is still a mysterious disease, and we still have a lot of questions. At the same time, I find the world of EoE fascinating.”
While controversial, there appears to be two distinct phenotypes among people with EoE symptoms. “Infants and toddlers have feeding difficulties, fail to thrive, with vomiting and bad reflux. School age children tend to have reflux and more vomiting and pain,” Soong says. “Late teenagers and adults usually present with food getting stuck and dysphagia, food impaction, upper abdominal pain and heartburn.”
In children, especially infants, food allergies seem to be more predominant in association with EoE. “Milk, eggs, soy, peanuts, and wheat tend to play a big role,” Soong says, “while the majority of teenagers and adults appear to be environmentally allergic. However, we also may find a food allergy in 40 to 50 percent of adults.
“Patients with EoE might also have asthma and eczema. I think it is interesting that you have people with allergic lungs, which is asthma, and people with allergic skin, which is eczema. Now we’re finding an esophagus that is allergic. Allergies are in places that come in contact with the air – eyes, nose, skin, and lungs. Why not the esophagus? It comes in contact with the air, too. It is also interesting that we are becoming more allergic as a nation, and all of a sudden this allergy pops up. It’s one of those diseases that you wouldn’t find if you weren’t looking for it. Now that we are looking for it, we’re finding it.”
Most EoE patients who have reflux symptoms see a gastroenterologist. “When these patients present with bad reflux, you are supposed to put them on a two-month trial of a proton pump inhibitor, do an endoscopy and biopsy. If the pathology report shows greater than 15 eosinophils per high power field, it’s likely to be EoE,” Soong says. “At that point, the allergist gets involved in the treatment. In children and adults, we do skin and patch testing for food allergies and environmental testing. Some patients elect to do an elimination diet.”
Once the EoE diagnosis is confirmed, there are several treatment options that have led to some controversy among physicians. “We can put the patient on elemental formula which works great if the patient is an infant, but not if she is school age or an adult,” Soong says. “We will try to find the problem food and eliminate it. Some people do a six-food elimination diet avoiding the major allergic foods – milk, eggs, wheat, soy, peanuts, and tree nuts – which can be tedious. We’ve found that the easiest medical treatment is to put the patient on a proton pump inhibitor and a swallowed steroid like budesonide or fluticasone. It’s like treating asthma of the esophagus.”
There is also controversy surrounding maintenance of the disease. “No one knows how long to treat these patients, and what the proper dosage and administration of these medicines is,” Soong says. “Then there is the question of endoscopy. Do you scope once they are asymptomatic? Do you scope years afterward? Nobody really knows. And no one knows what your end point is with these patients. We are dealing with a disease that has only attracted interest in the past 10 years. There is still a lot that is unknown about the natural history of EoE.”
Unfortunately, the asthma drugs required to treat EoE are not officially approved for use in EoE by the Federal Drug Administration (FDA). As a result, some insurance companies do not cover the high dosage levels needed to treat EoE.
“There are insurance issues because there is a lack of recognition of EoE since it is a new disease,” Soong says. “I think a lot of people, both insurance companies and physicians, have been behind the eight ball on this disease. Because these drugs are not FDA approved for EoE, some insurance carriers wonder why they have to pay for the drugs when the patient doesn’t have asthma, which is what the drugs are indicated for.”
Allergy testing and endoscopies on these patients also can cause problems with insurance. “In Alabama, the majority of patients are limited to 65 allergy tests every three years. With this disease, there are so many potential foods and allergens that can be the cause of the problem,” Soong says. “Patients often have to pay out of pocket for endoscopies and allergy testing since most insurance companies put them under the major medical deductible. Some patients do not get the proper work up for EoE because of this barrier. It is a big issue and needs to be on people’s radar.”
Soong hopes that more doctors will begin to recognize the symptoms of EoE. Researchers are studying new treatments for the disease, including a drug to inhibit interleukin (IL) 5, which stimulates eosinophil production. “There are two other products, Anti IL 13 and Anti IL 4,” he says. “It will be exciting to see where these studies lead us in the near future.”
