RESUMEN
Although swallowed topical steroids are effective in inducing histological remission in eosinophilic esophagitis (EoE), their efficacy is limited by treatment nonadherence. In this study, we objectively measured adherence rates to swallowed topical steroids in adolescents with EoE over the course of 8 weeks and analyzed the association between adherence rate, disease and demographic features, symptom severity, and medication-taking habit strength. We found that approximately 20% of adolescents with EoE were over-dosing on their medications. After excluding these patients, mean adherence rate was 67.0% (±19.4%) and median adherence rate was 63% (interquartile range 53%-88%). Adherence was not associated with demographic features, disease history, symptom severity, or quality of life but was associated with habit strength (Pearson r = 0.48, P = 0.04). These findings suggest that habit strength may serve as a potential target for interventions aimed at improving adherence in adolescents with EoE.
Asunto(s)
Esofagitis Eosinofílica , Humanos , Adolescente , Esofagitis Eosinofílica/diagnóstico , Fluticasona/uso terapéutico , Calidad de Vida , Esteroides/uso terapéutico , Administración OralRESUMEN
In 2022, the US Food and Drug Administration approved dupilumab for treatment of eosinophilic esophagitis (EoE). The aims of this study were to report physician and patient perspectives on initiating dupilumab. A 2-pronged approach was used: (1) data on physician prescribing practices was gathered via retrospective chart review of EoE patients prescribed dupilumab and (2) pediatric patients on dupilumab were approached to complete a questionnaire regarding reasons for initiation. During this time, 42 patients were prescribed dupilumab. From the physician's perspective, the primary reasons for dupilumab included nonresponse to topical corticosteroids (TCS) (52%), nonadherence (28%), adverse effects (10%), or to treat multiple atopic diseases (5%). The median dupilumab initiation time, from day prescribed to first injection, was 37 days [interquartile range (IQR) 37]. Almost all required prior authorization (PA) (98%), while 17% required letter of appeal and 2% required peer-to-peer. Fifteen patients (36%) completed the questionnaire portion of the study. From the patient's perspective, the primary reasons for dupilumab initiation included nonresponse to TCS (27%), nonadherence to TCS (27%), concern about adverse effects of TCS (7%), and treatment of multiple atopic diseases (33%). In conclusion, physicians are prescribing dupilumab primarily for nonresponse to TCS and almost all required PA with a long delay to starting dupilumab.
Asunto(s)
Fármacos Dermatológicos , Esofagitis Eosinofílica , Humanos , Niño , Esofagitis Eosinofílica/tratamiento farmacológico , Estudios Retrospectivos , Anticuerpos Monoclonales Humanizados/uso terapéutico , Glucocorticoides/uso terapéutico , Fármacos Dermatológicos/efectos adversos , Evaluación del Resultado de la Atención al Paciente , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of the study was to determine the mucosal microbiota associated with eosinophilic esophagitis (EoE) and eosinophilic gastritis (EoG) in a geographically diverse cohort of patients compared to controls. METHODS: We conducted a prospective study of individuals with eosinophilic gastrointestinal disease (EGID) in the Consortium of Eosinophilic Gastrointestinal Disease Researchers, including pediatric and adult tertiary care centers. Eligible individuals had clinical data, mucosal biopsies, and stool collected. Total bacterial load was determined from mucosal biopsy samples by quantitative polymerase chain reaction (PCR). Community composition was determined by small subunit rRNA gene amplicons. RESULTS: One hundred thirty-nine mucosal biopsies were evaluated corresponding to 93 EoE, 17 EoG, and 29 control specimens (18 esophageal) from 10 sites across the United States. Dominant community members across disease activity differed significantly. When comparing EoE and EoG with controls, the dominant taxa in individuals with EGIDs was increased ( Streptococcus in esophagus; Prevotella in stomach). Specific taxa were associated with active disease for both EoE ( Streptococcus , Gemella ) and EoG ( Leptotrichia ), although highly individualized communities likely impacted statistical testing. Alpha diversity metrics were similar across groups, but with high variability among individuals. Stool analyses did not correlate with bacterial communities found in mucosal biopsy samples and was similar in patients and controls. CONCLUSIONS: Dominant community members ( Streptococcus for EoE, Prevotella for EoG) were different in the mucosal biopsies but not stool of individuals with EGIDs compared to controls; taxa associated with EGIDs were highly variable across individuals. Further study is needed to determine if therapeutic interventions contribute to the observed community differences.
Asunto(s)
Esofagitis Eosinofílica , Microbiota , Adulto , Humanos , Niño , Esofagitis Eosinofílica/patología , Estudios ProspectivosRESUMEN
OBJECTIVE: To evaluate the impact of type and dose of swallowed topical steroids (STS) and concurrent steroid therapy on the development and resolution of adrenal insufficiency (AI) in pediatric eosinophilic esophagitis (EoE). METHODS: We performed a retrospective case-control study of pediatric EoE subjects in a single tertiary care center, who were treated with STS for at least 3 months and diagnosed with AI based on a peak stimulated cortisol level of <18 µg/dL (500 nmol/L). Steroid forms and doses, and endoscopy data were collected at the time of AI diagnosis and AI resolution or the last known evaluation. Steroid formulations were converted to a fluticasone-equivalent dose for analysis. RESULTS: Thirty-two EoE subjects with AI were identified, and 20 had AI resolution, including 12 who remained on lower dose STS. Eight of the 32 patients were also treated with extended-release budesonide (ER budesonide), which resulted in a 7-fold higher total daily steroid dose, and thus were analyzed separately. When the 24 cases that were not on ER budesonide were compared to the 81 controls, no difference was found in the STS dose nor total daily steroid dose, although the inhaled steroid dose had marginal significance. Peak eosinophil counts tended to increase when STS doses were decreased, except in subjects on ER budesonide at AI diagnosis. CONCLUSION: Altering the total daily steroid regimen can lead to resolution of AI in patients with EoE, though this may come at the expense of disease control.
Asunto(s)
Insuficiencia Suprarrenal , Esofagitis Eosinofílica , Humanos , Niño , Esofagitis Eosinofílica/complicaciones , Esofagitis Eosinofílica/tratamiento farmacológico , Esofagitis Eosinofílica/diagnóstico , Estudios Retrospectivos , Estudios de Casos y Controles , Reducción Gradual de Medicamentos , Budesonida/uso terapéutico , Insuficiencia Suprarrenal/tratamiento farmacológico , Insuficiencia Suprarrenal/inducido químicamente , Esteroides/uso terapéuticoRESUMEN
ABSTRACT: Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease. Patients with a childhood diagnosis require ongoing disease management in adulthood; however, knowledge of the patient experience during pediatric to adult healthcare transition is lacking. Here, an online survey captured patient perceptions of the challenges faced by patients with EoE in the United States during transition to adult healthcare, and which resources, if implemented, could better support transition. Of 67 respondents, 91% (nâ=â61) were under adult care at the time of survey completion. Aspects that respondents struggled with most included meal planning, food shopping, cooking/finding foods that did not exacerbate their condition, and knowledge of insurance coverage. Although most respondents reported confidence in having the knowledge to manage their EoE, almost half of the respondents worried about managing their condition in the future. Resources detailing diet, medication and insurance management strategies could support the transition to adult healthcare for patients with EoE.
Asunto(s)
Enteritis , Esofagitis Eosinofílica , Transición a la Atención de Adultos , Adulto , Niño , Esofagitis Eosinofílica/diagnóstico , Esofagitis Eosinofílica/terapia , Humanos , Transferencia de Pacientes , Encuestas y CuestionariosAsunto(s)
Esofagitis Eosinofílica , Niño , Esofagitis Eosinofílica/epidemiología , Humanos , Prevalencia , Salud RuralRESUMEN
BACKGROUND: Acid blockade is commonly prescribed in patients with cystic fibrosis (CF). Growing concerns, however, exist about its possible role in the pathophysiology of pulmonary infections. We aimed to investigate if acid blockade alters esophageal and respiratory microbiota leading to dysbiosis and inflammation. METHODS: We performed a cross sectional study of children with CF who were either prescribed acid blockade or not. Samples from the gastrointestinal and respiratory tracts were obtained and microbiome analyzed. Mixed effect models were used to compare outcomes between cohorts and across sampling sites. A random subject intercept was included to account for the multiple sampling sites per individual. RESULTS: A cohort of 25 individuals, 44% girls with median age of 13.8 years [IQR 11.2--14.8] were enrolled. Alpha diversity, total bacterial load, and beta diversity were similar across anatomic compartments, across the upper gastrointestinal tract, and in respiratory samples. Similar alpha diversity, total bacterial load, and beta diversity results were also observed when comparing individuals on versus those off acid blockade. IL-8 was elevated in the distal versus proximal esophagus in the whole cohort (Pâ<â0.01). IL-8 concentrations were similar in the distal esophagus in patients on and off acid blockade, but significantly greater in the proximal esophagus of subjects on treatment (Pâ<â0.01). CONCLUSIONS: On the basis of these data, acid blockade use does not appear to influence the microbiome of the aerodigestive tract in children with cystic fibrosis suggesting a complex interplay between these medications and the bacterial composition of the esophagus and lung.
Asunto(s)
Fibrosis Quística , Microbiota , Adolescente , Bacterias , Niño , Estudios Transversales , Fibrosis Quística/tratamiento farmacológico , Disbiosis , Femenino , Humanos , MasculinoRESUMEN
Abstract Objective: The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. Sources: A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. Summary of the findings: The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. Conclusions: Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.
Resumo Objetivo: Fornecer uma visão geral do diagnóstico e do tratamento da esofagite eosinofílica na prática clínica e aumentar a visibilidade da doença entre os pediatras. Fontes dos dados: Foi feita uma busca na literatura relevante nos bancos de dados Medline, Embase, CINAHL e consensos e diretrizes recentes foram revisados. Síntese dos dados: A definição de esofagite eosinofílica é baseada nos sintomas e na histologia. É importante excluir outras doenças associadas com inflamação esofágica predominantemente eosinofílica. Ainda não está claro se o aumento na prevalência é devido a um real aumento da incidência ou se é o resultado da maior suspeição diagnóstica. Várias opções para tratamento, inclusive inibidores de bomba de prótons, restrições dietéticas, esteroides tópicos deglutidos e dilatações endoscópicas têm sido usadas em pacientes pediátricos. Mais recentemente a eosinofilia esofágica responsiva a inibidores de bomba de prótons e a esofagite eosinofílica têm sido contempladas no mesmo espectro e os inibidores de bomba de prótons devem ser considerados como opção inicial no tratamento desses pacientes. Conclusões: A esofagite eosinofílica é uma doença relativamente nova com uma notável progressão da incidência e prevalência nas últimas 2-3 décadas e critérios diagnósticos estão em evolução constante. É importante entender melhor a patogênese dessa doença, os fatores predisponentes, a história natural e a categorização dos diferentes fenótipos para desenvolver estratégias diagnósticas e terapêuticas que vão ao encontro das necessidades clínicas dos pacientes.
Asunto(s)
Humanos , Niño , Esofagitis Eosinofílica/diagnóstico , Esofagitis Eosinofílica/terapia , Esofagoscopía , Dilatación , Inhibidores de la Bomba de Protones/uso terapéutico , Antiinflamatorios/uso terapéuticoRESUMEN
OBJECTIVE: The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. SOURCES: A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. SUMMARY OF THE FINDINGS: The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. CONCLUSIONS: Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.
Asunto(s)
Esofagitis Eosinofílica/diagnóstico , Esofagitis Eosinofílica/terapia , Antiinflamatorios/uso terapéutico , Niño , Dilatación , Esofagoscopía , Humanos , Inhibidores de la Bomba de Protones/uso terapéuticoRESUMEN
Clinical experiences and recent studies suggest that eosinophilic esophagitis (EoE) has the potential to induce caregiver (CG) and child stress. The specific sources of CG EoE-related stress remain uncertain. To address this, we performed a survey of CGs and youth attending a patient with EoE education symposium that measured potential stressful elements in their daily life. Our results indicated that CGs experienced most stress associated with purchasing, preparation, and completion of meals. We conclude that providers should consider this in choosing therapeutic approaches for children with EoE.
Asunto(s)
Ansiedad/etiología , Cuidadores/psicología , Dietoterapia/psicología , Esofagitis Eosinofílica/psicología , Comidas/psicología , Estrés Psicológico/etiología , Adolescente , Adulto , Ansiedad/diagnóstico , Niño , Preescolar , Esofagitis Eosinofílica/dietoterapia , Femenino , Encuestas Epidemiológicas , Humanos , Lactante , Masculino , Escalas de Valoración Psiquiátrica , Estrés Psicológico/diagnósticoRESUMEN
Propofol is a safe, well-tolerated anesthetic that is labeled as contraindicated in patients with egg or soy allergy. This contraindication has become increasingly problematic given the rising incidence of food allergy and eosinophilic esophagitis (EoE). To address this issue, we studied practice patterns of propofol use for esophagogastroduodenoscopies in children with EoE and food allergies at our institution. A retrospective observational study of 1365 esophagogastroduodenoscopies from January 2013 to June 2014 was performed. Data were analyzed using Student t tests, chi square tests, Fisher exact tests, and multivariable logistic regression. We found that propofol was used significantly less in patients with egg or soy allergy, and in patients with EoE, even after adjusting for the presence of food allergy. There was no difference in complication rates relative to propofol use. Propofol was used safely in pediatric patients with EoE and food allergy in this limited single-center review.
Asunto(s)
Anestésicos Intravenosos , Endoscopía del Sistema Digestivo , Esofagitis Eosinofílica , Hipersensibilidad a los Alimentos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Propofol , Adolescente , Anestésicos Intravenosos/efectos adversos , Niño , Preescolar , Colorado , Contraindicaciones de los Medicamentos , Esofagitis Eosinofílica/complicaciones , Esofagitis Eosinofílica/diagnóstico por imagen , Esofagitis Eosinofílica/terapia , Femenino , Hipersensibilidad a los Alimentos/complicaciones , Hipersensibilidad a los Alimentos/diagnóstico por imagen , Hipersensibilidad a los Alimentos/terapia , Humanos , Lactante , Recién Nacido , Masculino , Propofol/efectos adversos , Estudios RetrospectivosRESUMEN
OBJECTIVES: To examine whether maternal-child interaction during feedings was suboptimal in dyads in which the infant had gastroesophageal reflux disease (GERD) and to compare massage therapy to a nonmassage therapy sham treatment in improving the mother-child interaction in these dyads. DESIGN: In this randomized, controlled pilot study, infants received massage therapy (n=18) or a nonmassage touch/holding sham treatment (n=18). Mothers, data collectors, and the investigator who scored the feeding observations were blinded to group assignment. SETTINGS/LOCATION: Dyads were recruited from pediatric care providers in the Denver metropolitan area and online advertisements at the University of Colorado. Treatments were given in the home of the dyad. PARTICIPANTS: Healthy infants, born at 38-42 weeks gestational age, were 5-10 weeks of age at enrollment; had a score of at least 16 on the Infant Gastroesophageal Reflux Questionnaire-Revised; and were diagnosed with GERD by their pediatric provider. Mothers were English speaking and at least 18 years of age. INTERVENTIONS: Treatments were given for 30 minutes twice weekly for 6 weeks. A certified infant massage therapist administered massage, and a registered nurse or physical therapist experienced with infants administered the control treatment. OUTCOME MEASURES: Maternal and infant scores on the Nursing Child Assessment of Feeding Scale (NCAFS). RESULTS: NCAFS scores were significantly lower than national norms. Small to moderately sized effects showing improvement in the massage group relative to the nonmassage group were seen for Sensitivity to Cues, Social-Emotional Growth Fostering, Cognitive Growth Fostering, and Clarity of Cues (Cohen d) and ranged from 0.24 to 0.56. CONCLUSIONS: Mothers and infants with GERD experience significantly worse interactions than those without GERD. Massage given twice weekly by a professional trended toward improved interaction during feeding. Daily maternal administration of massage may have a positive effect on the relationship.