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Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study - 05/04/18

Doi : 10.1016/j.jaci.2017.08.038 
Javier Molina-Infante, MD, PhD a, b, , Ángel Arias, MSc, BSc b, c, Javier Alcedo, MD, PhD d, Ruth Garcia-Romero, MD, PhD e, Sergio Casabona-Frances, MD f, Alicia Prieto-Garcia, MD, PhD g, Ines Modolell, MD, PhD h, Pedro L. Gonzalez-Cordero, MD a, Isabel Perez-Martinez, MD, PhD i, Jose Luis Martin-Lorente, MD, PhD j, Carlos Guarner-Argente, MD, PhD k, Maria L. Masiques, MD l, Victor Vila-Miravet, MD m, Roger Garcia-Puig, MD n, Edoardo Savarino, MD, PhD o, Carlos Teruel Sanchez-Vegazo, MD p, Cecilio Santander, MD, PhD b, f, Alfredo J. Lucendo, MD, PhD b, q,
a Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Caceres, Spain 
b Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain 
c Research Unit, Hospital General Mancha Centro, Alcazar de San Juan, Ciudad Real, Spain 
d Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain 
e Department of Pediatrics, Hospital Universitario Miguel Servet, Zaragoza, Spain 
f Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain 
g Department of Allergy, Hospital General Universitario Gregorio Marañon, Madrid, Spain 
h Department of Gastroenterology, Consorci Sanitari Terrassa, Barcelona, Spain 
i Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain 
j Department of Gastroenterology, Hospital Universitario de Burgos, Burgos, Spain 
k Department of Gastroenterology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain 
l Department of Pediatrics, Hospital General de Granollers, Barcelona, Spain 
m Department of Pediatrics, Hospital Sant Joan de Deu, Barcelona, Spain 
n Department of Pediatrics, Hospital Universitari Mutua Terrassa, Barcelona, Spain 
o Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy 
p Department of Gastroenterology, Hospital Universitario Ramon y Cajal, Madrid, Spain 
q Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain 

Corresponding author: Javier Molina-Infante, MD, PhD, Department of Gastroenterology, Hospital Universitario San Pedro de Alcantara, Avda Pablo Naranjo s/n 10003, Caceres, Spain.Department of GastroenterologyHospital Universitario San Pedro de AlcantaraAvda Pablo Naranjo s/nCaceres10003SpainAlfredo J. Lucendo, MD, PhD, Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n 13700, Tomelloso, Spain.Department of GastroenterologyHospital General de TomellosoVereda de Socuéllamos, s/nTomelloso13700Spain

Abstract

Background

Numerous 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.

Objective

We sought to assess the effectiveness of a step-up dietary strategy for EoE.

Methods

We 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.

Results

One 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%.

Conclusions

A 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.

El texto completo de este artículo está disponible en PDF.

Key words : Eosinophilic esophagitis, diet, milk, wheat, six-food elimination

Abbreviations used : DSS, EoE, FFGED, hpf, IQR, PPI, SFGED, TFGED


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 Disclosure of potential conflict of interest: E. Savarino has consultant arrangements with Abbvie, MSD, Takeda, Malesci, and Sofar. C. T. Sanchez-Vegazo has received payment for lectures from Norgine and has received travel support from Norgine, Bama-Geve, and Allergan. The rest of the authors declare that they have no relevant conflicts of interest.


© 2017  American Academy of Allergy, Asthma & Immunology. Publicado por Elsevier Masson SAS. Todos los derechos reservados.
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Vol 141 - N° 4

P. 1365-1372 - avril 2018 Regresar al número
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