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Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study

2017; Elsevier BV; Volume: 141; Issue: 4 Linguagem: Inglês

10.1016/j.jaci.2017.08.038

1097-6825

Javier Molina‐Infante, Ángel Arias, Javier Alcedo, Ruth García‐Romero, Sergio Casabona, A. Prieto, Inés Modolell, Pedro L. Gonzalez-Cordero, Isabel Pérez‐Martínez, José Luis Martín-Lorente, Carlos Guarner‐Argente, M. Masiques, V Vila-Miravet, Roger García-Puig, Edoardo Savarino, Carlos Teruel, Cecílio Santander, Alfredo J. Lucendo,

Esophageal and GI Pathology

BackgroundNumerous dietary restrictions and endoscopies limit the implementation of empiric elimination diets in patients with eosinophilic esophagitis (EoE). Milk and wheat/gluten are the most common food triggers.ObjectiveWe sought to assess the effectiveness of a step-up dietary strategy for EoE.MethodsWe performed a prospective study conducted in 14 centers. Patients underwent a 6-week 2-food-group elimination diet (TFGED; milk and gluten-containing cereals). Remission was defined by symptom improvement and less than 15 eosinophils/high-power field. Nonresponders were gradually offered a 4-food-group elimination diet (FFGED; TFGED plus egg and legumes) and a 6-food-group elimination diet (SFGED; FFGED plus nuts and fish/seafood). In responders eliminated food groups were reintroduced individually, followed by endoscopy.ResultsOne hundred thirty patients (25 pediatric patients) were enrolled, with 97 completing all phases of the study. A TFGED achieved EoE remission in 56 (43%) patients, with no differences between ages. Food triggers in TFGED responders were milk (52%), gluten-containing grains (16%), and both (28%). EoE induced only by milk was present in 18% and 33% of adults and children, respectively. Remission rates with FFGEDs and SFGEDs were 60% and 79%, with increasing food triggers, especially after an SFGED. Overall, 55 (91.6%) of 60 of the TFGED/FFGED responders had 1 or 2 food triggers. Compared with the initial SFGED, a step-up strategy reduced endoscopic procedures and diagnostic process time by 20%.ConclusionsA TFGED diet achieves EoE remission in 43% of children and adults. A step-up approach results in early identification of a majority of responders to an empiric diet with few food triggers, avoiding unnecessary dietary restrictions, saving endoscopies, and shortening the diagnostic process.