Differences in Patient Characteristics, Treatment of EoE by Allergists and Gastroenterologists

Patients with eosinophilic esophagitis (EoE) may be managed by either gastroenterologists or allergists depending on their symptoms. A new poster presented at the American College of Allergy, Asthma and Immunology Annual Scientific Meeting, held November 10-14 in Louisville, KY, reviewed the characteristics of patients managed by either of these specialists.

Symptoms of EoE, which is caused by inflammation in the esophagus, include difficulty swallowing, food impact, abdominal pain and nausea. “Symptoms of EoE may persist despite current standard-of-care treatments, including pharmacologic therapies, elemental and/or elimination diets, and esophageal dilations, ultimately affecting patients’ health-related quality of life,” researchers, mostly from AstraZeneca, explained in the poster.

The poster analyzed real-world data using Adelphi Real World Disease Specific Programmes, which are multinational, point-in-time surveys. This data characterized patients with EoE in the United States and five European countries.

A total of 1001 patients with EoE 12 years or older with a biopsy-confirmed diagnosis of EoE — defined as esophageal count of ≥ 15 eosinophils/high-power field (eos/hpf) — were included in the study.

The majority (91%) were treated by gastroenterologists. Patients treated by gastroenterologists had a shorter average time since diagnosis: 32 months with gastroenterologists vs 22 months with allergists.

Additional baseline characteristics by specialist were:

• Patients treated by gastroenterologists were slightly younger: 36.1 years vs 39.4 years
• The mean age at diagnosis was 33.4 years for patients treated by gastroenterologists compared with 36.1 years for those treated by allergists
• The male to female ratio was similar: 67% of patients treated by allergists and 65% treated by gastroenterologists were male

A greater proportion of patients treated by allergists had comorbid atopic conditions, such as asthma (36% of patients with allergists vs 23% with gastroenterologists), allergic rhinitis (58% with allergists vs 21%) and atopic dermatitis (15% with allergists vs 7%). A greater proportion of patients seen by gastroenterologists had no comorbidities (39% with gastroenterologists vs 25% with allergists).

Diet, including eliminating potential trigger foods, is a common nonpharmacological treatment for eosinophilic esophagitis.

Compared with patients seen by gastroenterologists, a greater proportion of patients seen by allergists had the main criteria for investigating EoE prior to a diagnosis as food impaction (41% vs 31%) or choking on food (20% vs 6%). For patients seen by gastroenterologists, a greater proportion had the main criteria for investigating EoE as difficulty swallowing (40% vs 24%).

Dietary changes are a common nonpharmacological treatment for EoE. A quarter of all patients were currently on an elimination diet (26%) and 21% had previously attempted it. With elimination diet, patients omit a food or group of foods before the foods are reintroduced to determine which are triggering the inflammation. A smaller proportion were on (9%) or had tried (8%) elemental diet, in which all foods are removed and patients are exclusively fed an amino acid-based formula for at least 6 weeks.

Gastroenterologists were slightly more likely to try the elemental diet: 18% of patients seen by gastroenterologists were either on or had tried this diet compared with 11% of patients seen by allergists. Conversely, allergists were more likely to try elimination diet: 59% of patients seen by allergists were on or had tried an elimination diet compared with 46% of patients seen by gastroenterologists.

Only 11.9% of patients seen by allergists and 14.7% of those seen by gastroenterologists had a known current exact eosinophil count from a recent tissue biopsy. Of these patients, 36% seen by allergists and 60% seen by gastroenterologists had counts ≥ 15 eos/hpf.

Patients seen by allergists were more likely to have changed medication from initiation (32% vs 21%), and they were also treater for longer on average (1002.7 days vs 624.6 days). A slightly higher proportion of patients treated by gastroenterologists were on proton pump inhibitors (PPI) alone (27% vs 21%) although similar proportions of patients were on both PPI and topical corticosteroids (TCS) (36% seen by allergists and 35% seen by gastroenterologists). However, no patients seen by allergists were currently on TCS alone compared with 11% of patients seen by gastroenterologists.

Finally, gastroenterologists were more likely to perform esophageal dilation, which stretches the esophagus and is considered a short-term solution. This dilation followed admission to the emergency department or hospital for 36% of patients seen by gastroenterologists vs only 9% of patients seen by allergists.