Nixing Food Triggers Could Ease More Eosinophilic GI Disorders

— Remission in stomach and duodenum, improved symptoms seen

by
Elizabeth Short, Staff Writer, MedPage Today
July 20, 2023

An amino-acid based diet may help provide relief for patients with eosinophilic gastritis or gastroenteritis (EoG/EoGE), a small prospective study found.

All 15 participants experienced a complete histologic remission in both the stomach (from 50 to 11 eosinophils per high-power microscopic field of gastric or duodenal biopsy sample [eos/hpf], P<0.001) and in the duodenum (from 49 to 16 eos/hpf, P=0.001) following 6 weeks of the amino acid-based, nutritionally complete elemental formula (ELE) diet, reported researchers led by Nirmala Gonsalves, MD, of the Northwestern University Feinberg School of Medicine in Chicago.

Clinical and endoscopic improvements were observed following the ELE diet when assessing histologic measures for EoG and patient-reported outcomes such as Severity of Dyspepsia Assessment pain intensity and the Patient-Reported Outcomes Measurement Information System depression domain, according to the findings in the Journal of Allergy and Clinical Immunology.

Gonsalves and colleagues noted that the ELE formula had been the sole nutritional source for patients during the 6 weeks of the study period, with potential additional formulas or supplements used based on an individual patient’s needs and a dietitian assessment.

In EoG/EoGE, eosinophils infiltrate the gastric and/or intestinal tissue and may reach varying bowel layers. EoG/EoGE is estimated to affect approximately 22 to 28 people per 100,000, according to the investigators.

EoG and EoGE fall under the umbrella of eosinophilic gastrointestinal disorders, which also include the relatively better-studied and more prevalent eosinophilic esophagitis (EoE).

Different steroid treatments, proton pump inhibitors, and dietary therapies such as targeted exclusion diets, are among the treatments used to manage these conditions — with the monoclonal antibody dupilumab (Dupixent) becoming the first FDA approved treatment for EoE last year.

“Although elimination and elemental diets are highly effective treatments to reduce mucosal inflammation in EoE, dietary therapy has not been well studied in EoG/EoGE. EoG/EoGE treatment largely relies on systemically active immunosuppressive agents (e.g., corticosteroids), although clinical trials are investigating biologic agents,” the study authors wrote.

“Although corticosteroids are effective at reducing eosinophilic inflammation, their long-term adverse effects limit their use as a maintenance therapy. As a result of the significant morbidity of these chronic illnesses and the paucity of data on effective and safe treatment options, improved therapeutic options are needed,” they added.

During the diet intervention, a single serious adverse event (hyponatremia) was reported in one subject who withdrew from the study. Researchers noted that the patient was experiencing renal insufficiency and using several diuretics. They also found that the patient took “significantly less formula than self-reported and consumed more free water than advised.”

Other reported adverse events were ultimately not linked to the study.

Nonetheless, Gonsalves’s group urged patients suffering from EoG/EoGE to seek care with a “trained team with proper dietary support” if they wish to attempt ELE treatment, particularly if they are also suffering from other conditions such as chronic kidney disease. Varying levels of cost and coverage of the formula may also impact access to care, the group noted.

A total of 15 adult participants were included in the single-center study. Average age was 37.7 and the population was 47% male. On average, patients had been experiencing symptoms for 8.8 years prior to the trial. Common patient symptoms were abdominal pain, dysphagia, diarrhea, nausea, and vomiting.

Thirteen participants agreed to attempt the reintroduction of foods following the study. Of those patients, 11 opted to receive a follow-up endoscopy, which showed a histologic recurrence (greater than or equal to 30 eos/hpf) in the stomach in 73% of patients and in the duodenum in 64%.

The remaining two patients who did not opt to receive an endoscopy did experience a resurgence of symptoms but removed the trigger food instead.

The most common findings during endoscopy were erythema, granularity, and erosions/ulcers. Most of the participants experienced multi-gastrointestinal segment involvement of their symptoms and had concomitant atopic disorders.

A major limitation of the study was its lack of a placebo arm such as a sham diet with allergens. Researchers also noted that among the patients who participated in reintroduction, there were some who stopped the use of allergenic foods prior to endoscopy.

Gonsalves and colleagues encouraged further research both into treatment and the mechanisms of EoG/EoGE.

“Development of minimally invasive tools or biomarkers to replace endoscopy for disease activity assessment could provide additional clarity in future studies,” they wrote. “These data do, however, substantiate that individuals with EoG/EoGE have a multitude of food triggers driving their disease process, unlike individuals with EoE alone, who commonly have only single food triggers.”