Clinicians should conduct regular, structured follow-up on treatments for eosinophilic esophagitis (EoE), according to an expert panel.
“Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings,” write Ulrike von Arnim, MD, from University Hospital Magdeburg, in Magdeburg, Germany, and an international team of colleagues in Clinical Gastroenterology and Hepatology.
Although medicine and diet can control EoE, there is presently no cure, and long-term management is needed to prevent recurrence and long-term effects such as esophageal remodeling, fibrosis, and stricture, the researchers say.
Yet they could find no evidence-based recommendations for clinical monitoring of the condition.
With the participation of The International Gastrointestinal Eosinophil Researchers (TIGER) and the European Consortium for Eosinophilic Diseases of the GI Tract (EUREOS), they assembled a team of 18 gastroenterologists, pathologists, and allergists from the United States and Western Europe with expertise in the condition.
Almost all panelists had more than 10 years of subspecialty EoE care and more than five relevant research publications. All were members of TIGER or EUREOS. The panel met by video conferencing and responded to surveys to develop a consensus about why, by what means, and when to monitor patients with EoE.
The group reached 75% or greater agreement on 11 statements on these subjects.
Regular follow-ups are needed because they enable clinicians to detect whether treatments have stopped working, improve therapy adherence, and introduce patients to any new treatments that become available, while preventing gaps in care that can worsen outcomes, the group writes.
Symptoms don’t give a precise indication of esophageal healing and shouldn’t be the sole measure for disease activity, the experts write. They recommend other approaches to monitoring, including biopsies. They also endorse the Endoscopic Reference Score as an outcome measure.
The panel recommends noninvasive tissue sampling, mentioning the esophageal string test and the Cytosponge as examples, but calls for more research on these two techniques.
Blood markers, oral swabs, breath condensates, and stool and urine samples are not recommended as approaches for monitoring EoE, they write.
The optimal interval to measure the efficacy of a therapy is more difficult to decide, the panel notes.
“The clinician’s decision should take into account the clinical severity of the disease, estimated risk of imminent subsequent food impaction, presence of stenosis, as well as mode of action and reported outcome of the chosen medical, dietary, or mechanical treatment,” they write. Intervals from 6 to 24 weeks may be appropriate, they add.
For diets and topical corticosteroids, they agree on an interval of 8 to 12 weeks to confirm remission but say a longer time might be preferred for slower-acting therapies, such as monoclonal antibodies.
The panel had the most trouble reaching a consensus on how often to follow up on patients whose disease is in remission or is stable. They settled on 12 to 24 months after the last endoscopy. Any longer than 2 years risks missing increased disease activity, they write.
This follow-up should include assessment of symptoms and a gastrointestinal endoscopy in cases of relapse or suspected stricture, as well as when treatment modification is being considered or when assessment of histological activity is desired, the panel recommends.
Almost all the panelists disclosed financial relationships with pharmaceutical or medical device companies.
Clin Gastroenterol Hepatol. Published online December 23, 2022. Abstract
Laird Harrison writes about science, health, and culture. His work has appeared in national magazines, in newspapers, on public radio, and on websites. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at www.lairdharrison.com or follow him on Twitter @LairdH.
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