Long-Term Considerations in the Treatment of Eosinophilic Esophagitis

Long term use of PPIs and an elimination diet with insufficient nutrients is correlated with lower bone mass density in children with EoE.

Adrenal insufficiency can occur in children with the use of swallowed topical steroids.

• One systematic review showed that 16% of pooled patients with EoE (children and adults) were identified as having adrenal insufficiency secondary to swallowed topical steroids.
• The risk of adrenal insufficiency for short-term (<12 weeks) topical corticosteroids is negligible.
• The risk of adrenal insufficiency in children with EoE who are taking topical corticosteroids for atopic conditions or inhaled steroids for asthma is increased because of a cumulative dose.

Monitoring Control of EoE

Given the progressive nature of fibrosis in the esophagus of patients with EoE and the negative effects of remodeling of the esophagus on quality of life, monitoring for active EoE is necessary.

• EoE is the most common cause of esophageal perforation, usually occurring spontaneously at the time of food bolus impaction.

Monitoring of patients with EoE can be performed by using multiple complementary methods, including:

• Tracking clinical severity by using validated instruments during follow-up visits

Periodic endoscopy and biopsy or other less invasive sampling when appropriate

Monitoring Mental Health Issues

Depression is more common in patients with EoE than in the general population, and the prevalence increases with age. Regular screening for depression in patients with EoE is indicated.

In addition to depression, functioning at school, anxiety, poor sleep and social difficulties need to be monitored over the long term and referrals made to mental health professionals when indicated.

Multidisciplinary approaches to treatment have been shown to improve adherence to diet and improve the quality of life of patients with EoE.

• When possible, refer the patient to a dedicated EoE clinic or to a dietitian.

Treatment choice is greatly influenced by family functioning. For example, some diet choices are too onerous or costly for a family to maintain. Any reduction in family functioning can lead to lower quality of life and cause stress for patients and their families.

Involving the Patient and Parent in the Decision-making Process

Adherence to a treatment plan is crucial, given that the disease worsens when treatment is not implemented effectively. Therefore, a treatment plan that the family and patient have been involved in devising and are motivated to implement is critical.

The psychological and physiological effects of dietary therapy are substantial and should be understood and discussed with patients with EoE and their caregivers.

• Dietary restrictions can sometimes be costly and more difficult to implement, particularly when controlling food exposures outside of the home.
• If a parent is opposed to long-term steroid use in their child, then this opinion must be considered when recommending a treatment plan.
• The risks and benefits of each type of treatment—medical and dietary—should be fully explained and understood by the family (and patient, if the child is old enough), prior to initiation.
• Children who have multiple caregivers or reside in more than one home (eg, because of divorced or unmarried parents) may have challenges with adherence to any form of therapy.

The treatment plan should be discussed as children reach developmental milestones. Examples of issues to weigh and discuss include the following:

• Social exclusion can be common with dietary restrictions, because of the physical difficulties of eating in public and the restriction on dietary content with an exclusion diet. This may be less important for very young children and more important for older children, who can be increasingly involved in social settings.
• The drawbacks of dietary exclusion diets in terms of the development of oral feeding skills and taste development are minimized as children age beyond 3 years.
• Swallowed topical steroids are effective in minimizing inflammation and reducing stricture formation; however, children with other atopic diseases may have a higher burden of absorbed steroids. Monitoring for side effects of these cumulative exposures becomes more critical in these cases.

Each family has unique considerations and concerns. Treatment failure should always include a discussion of adherence in a nonjudgmental fashion. If a treatment is too onerous to implement within a family, this is not a failure of the family but a recognition of the difficulties of the treatment option in the particular family setting.

The development of this information was made possible through support from Sanofi and Regeneron.