Clinical management of eosinophilic esophagitis – a nationwide survey among gastroenterologists in Germany

 

 Buy Article Permissions and Reprints

Abstract

Background Eosinophilic esophagitis (EoE) is an increasingly recognized immune-mediated esophageal disease and a common cause for dysphagia and food bolus obstruction. The aim of this study was to evaluate the current clinical management of EoE among adult gastroenterologists in Germany.

Methods We performed a cross-sectional study of 1393 adult gastroenterologists using a questionnaire containing 22 questions to general, diagnostic, and therapeutic aspects of EoE. The self-administered online survey was conducted between November 2017 and February 2018. Data capture and analysis was performed using SurveyMonkey.

Results The overall responder rate was 29.6 %. More than half of the responders (54.9 %) felt to observe a significant increase of EoE patients. The EREFS score was mostly either unknown (44.3 %) or not routinely used (52.2 %). If EoE was suspected, most responders obtained multiple esophageal biopsies (n = 3 – 4: 35.7 %; n > 4: 61.6 %). The preferred primary treatment was proton pump inhibitors (PPI) in 37.2 % and topical steroids in 35.0 % of responders. PPI regimens were highly diverse, with only half of responders using high-dose PPI regimens. Allergy testing was often initiated (always 25.4 %, sometimes 48.9 %). The most common dietary therapy was 6-food elimination diet (52 %), followed by allergy test-directed diets (16 %) and 2-food elimination diet (16.5 %). The majority of responders indicated a need for long-term treatment (i. e., 23 % of responders in > 50 % their patients and 47.7 % of responders in 25 – 50 % of their patients).

Conclusions Among gastroenterologists in Germany, substantial variation in the adherence to published EoE guidelines appears to exist. This indicates the need for intensified education and national guidelines in order to optimize and harmonize the clinical management of EoE patients.

Zusammenfassung

Hintergrund Die eosinophile Ösophagitis (EoE) ist eine zunehmend häufig erkannte, immunvermittelte Erkrankung der Speiseröhre und eine der häufigsten Ursachen für Dysphagie und Bolusobstruktionen. Ziel dieser Umfrage war es, das gegenwärtige klinische Management der EoE unter Gastroenterologen in Deutschland zu untersuchen.

Methodik Wir führten eine Querschnittsstudie unter 1393 Gastroenterologen (bng, ALGK) mittels eines Fragebogens durch, der 22 Fragen zu allgemeinen, diagnostischen und therapeutischen Aspekten der EoE enthielt. Die online-Umfrage erfolgte zwischen November 2017 und Februar 2018. Die Daten wurden mittels SurveyMonkey erfasst und analysiert.

Ergebnisse Die Responderrate betrug 29,6 %. Mehr als die Hälfte der Responder (54,9 %) gaben an, eine signifikante Zunahme von EoE-Patienten zu beobachten. Der EREFS-Score war in der Mehrzahl entweder unbekannt (44,3 %) oder wird in der Routine nicht verwendet (52,2 %). Bei Verdacht auf EoE entnahmen die Mehrzahl multiple Ösophagusbiopsien (n = 3 – 4: 35,7 %, n > 4: 61,6 %). Die bevorzugte Initialtherapie waren PPI (37,2 %) oder topische Steroide (35 %). Die PPI-Regime waren sehr divers. Nur in der Hälfte der Fälle wurde eine hochdosierte PPI-Therapie durchgeführt. Eine Allergietestung wurde häufig veranlasst (immer: 25,4 %, manchmal: 48,9 %). Die häufigste dietätische Therapie war die 6-Food-Eliminationsdiät (52 %), gefolgt von der Allergietest-gesteuerten Diät (16 %) und der 2-Food-Eliminationsdiät (16 %). Die Mehrzahl der Responder sahen die Notwendigkeit einer Langzeittherapie (in > 50 % der Patienten: 23 %, in 25 – 50 % der Patienten: 47,7 %).

Schlussfolgerung Unter Gastroenterologen in Deutschland gibt es eine substantielle Variation in der Adhärenz zu publizierten Leitlinien der EoE. Dieser Befund unterstreicht die Notwendigkeit einer intensiveren Fortbildung und einer nationalen Leitlinie, um eine Optimierung und Harmonisierung in der klinischen Versorgung von EoE-Patienten sicherzustellen.

• References

• 1 Furuta GT, Katzka DA. Eosinophilic esophagitis. N Engl J Med 2015; 373: 1640-1648
  CrossrefPubMedGoogle Scholar
• 2 Dellon ES, Hirano I. Epidemiology and natural history of eosinophilic esophagitis. Gastroenterology 2018; 154: 319-333
  CrossrefPubMedGoogle Scholar
• 3 Schoepfer AM, Safroneeva E, Bussmann C. et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology 2013; 145: 1230-1236
  CrossrefPubMedGoogle Scholar
• 4 Warners MJ, Oude Nijhuis RAB, de Wijkerslooth LRH. et al. The natural course of eosinophilic esophagitis and long-term consequences of undiagnosed disease in a large cohort. Am J Gastroenterol 2018; 113: 836-844
  CrossrefPubMedGoogle Scholar
• 5 Jensen ET, Kappelman MD, Martin CF. et al. Health-care utilization, costs, and the burden of disease related to eosinophilic esophagitis in the United States. Am J Gastroenterol 2015; 110: 626-632
  CrossrefPubMedGoogle Scholar
• 6 Furuta GT, Liacouras CA, Collins MH. et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007; 133: 1342-1363
  CrossrefPubMedGoogle Scholar
• 7 Liacouras CA, Furuta GT, Hirano I. et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3-20
  CrossrefPubMedGoogle Scholar
• 8 Papadopoulou A, Koletzko S, Heuschkel R. et al. Management guidelines of eosinophilic esophagitis in childhood. J Pediatr Gastroenterol Nutr 2014; 58: 107-118
  CrossrefPubMedGoogle Scholar
• 9 Dellon ES, Gonsalves N, Hirano I. et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol 2013; 108: 679-692
  CrossrefPubMedGoogle Scholar
• 10 Lucendo AJ, Molina-Infante J, Arias A. et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J 2017; 5: 335-358
  CrossrefPubMedGoogle Scholar
• 11 Dellon ES, Liacouras CA, Molina-Infante J. et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology 2018; 155: 1022-1033
  CrossrefPubMedGoogle Scholar
• 12 Hiremath G, Vaezi MF, Gupta SK . et al. Management of esophageal food impaction varies among gastroenterologists and affects identification of eosinophilic esophagitis. Dig Dis Sci 2018; 63: 1428-1437
  CrossrefPubMedGoogle Scholar
• 13 Eluri S, Book WM, Kodroff E . et al. Lack of knowledge and low readiness for health care transition in eosinophilic esophagitis and eosinophilic gastroenteritis. J Pediatr Gastroenterol Nutr 2017; 65: 53-57
  CrossrefPubMedGoogle Scholar
• 14 Hirano I, Moy N, Heckman MG. et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013; 62: 489-495
  CrossrefPubMedGoogle Scholar
• 15 Dellon ES, Erichsen R, Baron JA. et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther 2015; 41: 662-670
  CrossrefPubMedGoogle Scholar
• 16 Giriens B, Yan P, Safroneeva E. et al. Escalating incidence of eosinophilic esophagitis in Canton of Vaud, Switzerland, 1993–2013: a population-based study. Allergy 2015; 70: 1633-1639
  CrossrefPubMedGoogle Scholar
• 17 Warners MJ, de Rooij W, van Rhijn BD. et al. Incidence of eosinophilic esophagitis in the Netherlands continues to rise: 20-year results from a nationwide pathology database. Neurogastroenterol Motil 2017 Jul 26 [Epub ahead of print]
  PubMedGoogle Scholar
• 18 Rhijn BD, Warners MJ, Curvers WL. et al. Evaluating the endoscopic reference score for eosinophilic esophagitis: moderate to substantial intra- and interobserver reliability. Endoscopy 2014; 46: 1049-1055
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Dellon ES, Cotton CC, Gebhart JH. et al. Accuracy of the eosinophilic esophagitis endoscopic reference score in diagnosis and determining response to treatment. Clin Gastroenterol Hepatol 2016; 14: 31-39
  CrossrefPubMedGoogle Scholar
• 20 Wechsler JB, Bolton S, Amsden K. et al. Eosinophilic esophagitis reference score accurately identifies disease activity and treatment effects in children. Clin Gastroenterol Hepatol 2018; 16: 1056-1063
  CrossrefPubMedGoogle Scholar
• 21 Rhijn BD, Verheij J, Smout AJ. et al. The endoscopic reference score shows modest accuracy to predict histologic remission in adult patients with eosinophilic esophagitis. Neurogastroenterol Motil 2016; 28: 1714-1722
  CrossrefPubMedGoogle Scholar
• 22 Gonsalves N, Yang GY, Doerfler B. et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 2012; 142: 1451-1459
  CrossrefPubMedGoogle Scholar
• 23 Lucendo AJ, Arias Á, González-Cervera J. et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol 2013; 131: 797-804
  CrossrefPubMedGoogle Scholar
• 24 Eckmann JD, Ravi K, Katzka DA. et al. Efficacy of atopy patch testing in directed dietary therapy of eosinophilic esophagitis: a pilot study. Dig Dis Sci 2018; 63: 694-702
  CrossrefPubMedGoogle Scholar
• 25 Miehlke S, Hruz P, Vieth M. et al. A randomised, double-blind trial comparing budesonide formulations and dosages for short-term treatment of eosinophilic oesophagitis. Gut 2016; 65: 390-399
  CrossrefPubMedGoogle Scholar
• 26 Lucendo AJ, Miehlke S, Schlag C. et al. Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-controlled Trial. Gastroenterology 2019; DOI: https://doi.org/10.1053/j.gastro.2019.03.025.
  CrossrefPubMedGoogle Scholar
• 27 Gomez-Torrijos E, Garcıa-Rodrıguez R, Castro-Jimenez A. et al. The efficacy of step-down therapy in adult patients with proton pump inhibitor-responsive oesophageal eosinophilia. Aliment Pharmacol Ther 2016; 43: 534-540
  CrossrefPubMedGoogle Scholar
• 28 Dellon ES, Liacouras CA, Molina-Infante J. et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology 2018; 155: 1022-1033
  CrossrefPubMedGoogle Scholar
• 29 Kuchen T, Straumann A, Safroneeva E. et al. Swallowed topical corticosteroids reduce the risk for long-lasting bolus impactions in eosinophilic esophagitis. Allergy 2014; 69: 1248-1254
  CrossrefPubMedGoogle Scholar
• 30 Greuter T, Safroneeva E, Bussmann C . et al. Maintenance treatment of eosinophilic esophagitis with swallowed topical steroids alters disease course over a 5-year follow-up period in adult patients. Clin Gastroenterol Hepatol 2019; 17: 419-428
  CrossrefPubMedGoogle Scholar
• 31 Chang JW, Saini SD, Mellinger JL. et al. Management of eosinophilic esophagitis is often discordant with guidelines and not patient-centered: results of a survey of gastroenterologists. Dis Esophagus 2019 Jan 31 [Epub ahead of print]
  PubMedGoogle Scholar