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Wishing friends, family and colleagues a healthy and happy New Year.
Morning in Sandy Springs, GA
A recent retrospective study (N Nguyen et al. Clin Gastroenterol Hepatol 2019; 17: 2455-2462) describe the feasibility of unsedated transnasal endoscopy (TNE) for monitoring eosinophilic esophagitis (EoE) in children (n=190, subject ages 3-22 years).
TNE was facilitated by distraction with either video google or virtual reality (starting 2016). NPO time was 2 hours before the TNE.
- Over 294 TNEs were completed from 300 attempts (98% success)
- Cost of TNE was halved: $4393 compared to $9444 for EGD (does not count pathology costs)
- Adverse events: 8 (2.7%) with vomiting, 9 (3.1%) spit up, 11 (3.7%) with epistaxis
- By 2017, TNE accounted for 31.8% of upper endoscopies in 2017
The authors recommend that TNE be offered starting at age 5 years in those without a known stricture.
My take: I am looking forward to less invasive/less costly ways of monitoring treatment response in EoE. I think TNE can lower costs –though I am a little surprised that the cost of TNE in their institution was still more than $4000. In our outpatient endoscopy center, costs for an upper endoscopy/biopsy with anesthesia are typically about one-third the cost of an EGD in their study and about three-fourths the cost of a study TNE.
Related study: A Krigel et al. Clin Gastroenterol Hepatol 2019; 17: 2489-96. This study showed increasing use of anesthesia assistance (AA) for colonoscopy in adults from 16.7% in 2006 to 58.1% in 2015. This data was derived from the Premier Perspective database with more than 4.6 million patients who had an outpatient colonoscopy. AA was associated with a median increase in cost of $182 for patients with commercial insurance.
Related blog post: Waiting for the String Test for EoE
A recent study (Limketkai BN, et al. Gut. 2019;doi:10.1136/gutjnl-2018-318074.) shows that the likelihood of eosinophilic esophagitis (EoE) is higher in patients with inflammatory bowel disease (IBD) and that the likelihood of IBD is higher in EoE patients.
Summary from Healio Gastroenterology –Risk for EoE higher in patients with IBD, and vice versa:
- Researchers conducted a prospective cohort analysis using the Truven MarketScan database from 2009 to 2016 to define the epidemiology and clinical implications of concurrent EoE and IBD diagnoses.
- Among their cohort comprising 134,013,536 individuals, the incidence of EoE was 23.1 per 100,000 person-years, CD was 51.2 and ulcerative colitis was 55.2.
- Compared with patients without either diagnosis, the risk for EoE was higher in patients with CD (IRR = 5.4, P < .01; prevalence ratio [PR] = 7.8, P < .01) and UC (IRR = 3.5, P < .01; PR = 5, P < .01). Meanwhile, the risk for IBD was higher among patients with EoE (CD: IRR = 5.7, P < .01; PR = 7.6, P < .01; UC: IRR = 3.4, P < .01; PR = 4.9, P < .01).
A recent study (I Hirano et al. Gastroenterol 2019; 156: 592-603) showed that RPC4046, a monoclonal antibody against IL13 is a promising agent for eosinophilic esophagitis. This multicenter double-blind study with 99 adults compared RPC4046 at doses of either 180 mg or 360 mg to placebo for 16 weeks. Endoscopy was performed at baseline and at 16 weeks. The study population included a high number who were considered steroid-refractory and excluded patients who were responsive to proton pump inhibitors. The study drug was administered initially as an IV load followed by weekly subcutaneous injections.
- Mean changes in esophageal eosinophil count dropped by 94.8 in patients receiving 180 mg dosing and 99.9 in patients receiving 360 mg dosing. In contrast, placebo-treated patients had a meager reduction of 4.4.
- In this phase II study, there were no serious safety issues identified
- There were no significant changes relative to placebo in dysphagia symptoms using the DSD (dysphagia symptom diary) composite score. Though there was improvement in global PRO measures compared to placebo.
There is an associated editorial (pg 545) explains the need for better therapies. While both dietary therapies and topical steroids are likely effective in >70%, dietary therapy is plagued by problems with long-term adherence and there may become less effective with longer-term administration.
My take: Particularly for patients with refractory EoE, newer therapies are needed. Given the chronic nature of EoE, cost of new treatments could be another hurdle.
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Briefly noted: ET Jensen et al. JPGN 2019; 68: 50-5. This retrospective study with 409 patients with eosinophilic esophagitis (EoE) examined longitudinal growth over 12 months. “In general, treatment approach was not associated with any significant increase or decrease in expected growth.” In a subset of patients with combined elemental diet and topical steroids (n=13), there was a subtle decrease in linear growth with a change in height z-score of -0.04, CI -0.08 to -0.01. Interestingly, in these patients with EoE, the baseline height z-scores were lower than expected indicating that a subset may have impaired growth prior to treatment.
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pictures from Zabriskie Point at sunrise, Death Valley
Briefly noted: SC Shah, H Khalili et al. Gastroenterol 2018; 155: 1079-89.
This study evaluated pooled data with 207,600 incident cases of IBD from a population of 478 million. Key findings:
- Female patients had lower a lower risk of Crohn’s disease during childhood until 10-14 years of age, but then a risk afterwards
- For ulcerative colitis, there was a divergence in risk after 45 years of age, when men had a significantly higher incidence.
My take: the differences indicate that genetic factors (men with a Y chromosome and only one chromosome X) along with sex hormones play a role in the pathogenesis of IBD.
Graphs depict Female/Male Incidence Rate Ratio
AGREE proceedings: Briefly noted: ES Dellon, CA Liacouras, J Molina-Infante, GT Furuta et al. Gastroenterology 2018; 155: 1022-33. This report provides updated recommendations from AGREE conference –which have been widely cited previously on this blog and elsewhere. One of the remarkable features on this report is the fact that there are 64 authors (by my count) –thus reading the affiliations and the conflict of interest disclosures alone would take some time.
For a good review on this topic:
According to a recent retrospective study (CC Reed et al. Clin Gastroenterol Hepatol 2018; 16: 1667-9) the time to diagnosis of eosinophilic esophagitis (EoE) has NOT improved between 2000 and 2014. In this single tertiary-care center study with 677 cases, the predicted length of symptoms prior to diagnosis was the following:
- 2000-2006: 6.1 years
- 2007-2011: 7.2 years
- 2011-2014: 7.2 years
While in the pediatric cohort the trend was the same, the length of symptoms preceding diagnosis was shorter: 2.8 years, 3.5 years and 3.7 years respectively for the above-mentioned time periods.
My take: In GI circles, EoE is quickly considered for a variety of clinical presentations. This study suggests that
- #1 for families and primary care doctors that many are unaware of this entity
- #2 the symptoms of EoE are often insidious
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