Tag Archives: food reintroduction

Normalizing Diet with Dupilumab Therapy

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N Wolfest et al. Clin Gastroenterol Hepatol 2026; 24: 1271-1279. Open Access! Efficacy of Dupilumab on Facilitated Food Reintroduction in Eosinophilic Esophagitis

Methods: This open-label pilot study — patients who demonstrated disease control in the dupilumab run-in stage were able to continue into the food reintroduction stage for a total of 52 weeks. Reintroduction of trigger foods occurred at months 3, 6, and 9, while continuing on dupilumab treatment. Symptoms, histology, endoscopy, and esophageal diameter were compared prior to and following every phase of food reintroduction to month 12. All patients had previously failed trigger food reintroduction on their current EoE medication.

Key findings:

Dupilumab effectiveness: At month 3 of the dupilumab run-in stage, 17 of 19 evaluable patients (89%) per protocol had a PEC (peak eosinophil count) of <6 eos/hpf. One patient had a PEC of 6 eos/hpf but was permitted to proceed to the food reintroduction stage.

Food reintroduction:

  • Reintroduction of an EoE trigger food was successful in 86% of instances (54/63), as defined by a PEC <6 eos/hpf and no symptoms
  • At month 6, 75% of patients (12/16) successfully reintroduced an EoE trigger food, and, as portion size was increased or additional trigger foods were added, 93% (13/14) and 79% (11/14) successfully introduced EoE trigger foods at months 9 and 12, respectively
  • By the end of the study, 5 patients successfully achieved unrestricted serving sizes of an EoE trigger food without worsening esophageal biopsies
  • The mean PEC did not significantly change following food reintroduction at month 6 (5.3 [SD, 8.9]), month 9 (1.3 [SD, 2.8]), or month 12 (2.6 [SD, 4.5]) (see Figures below)

My take (borrowed in part from authors): For most newly-diagnosed patients, the majority prefer medical therapy over dietary restricitons. In those currently managed with dietary restrictions, “dupilumab treatment may provide a safe method for patients with EoE to gradually taper elimination diets for some trigger foods.”

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Useful Information on Eosinophilic Disorders

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A review (JB Wechsler et al. J Asthma Allergy 2014; 7: 85-94) provides practical advice on dietary management of eosinophilic esophagitis (EoE); the section on food reintroduction from elemental diets for patients with EoE is particularly helpful.  They start with typically less allergenic foods (group A) to most allergenic (group D) -from their Table 2:

Group A:

  • Vegetables (nonlegume): carrots, squash, sweet potato, white potato, string beans, broccoli, lettuce, beets, asparagus, cauliflower, Brussel sprouts
  • Fruit (noncitrus, nontropical) apples, pear, peaches, plum, apricot, nectarine, grape, raisins
  • Vegetables: tomatoes, celery, cucumber, onion, garlic, and other vegetables

Group B

  • Citrus fruit: orange, grapefruit, lemon, lime
  • Tropical fruit: banana, kiwi, pineapple, mango, papaya, guava, avocado
  • Melons: honeydew, cantaloupe, watermelon
  • Berries: strawberry, blueberry, raspberry, cherry, cranberry

Group C

  • Legumes: lima beans, chickpeas, white/black/red beans
  • Grains: oat, barley, rye, other grains
  • Meat: lamb, chicken, turkey, pork

Group D

  • Fish/shellfish
  • Corn
  •  Peas
  • Peanut
  • Wheat
  • Beef
  • Soy
  • Egg
  • Milk

Also, this review includes a long list of “freebie” foods allowed while on elemental diet, including artificial flavors/colors, corn syrup, oils, salt, crystal lite, and many others.

The authors note that “in our practice, the period of exclusive elemental formula is limited to 4 weeks prior to therapeutic assessment by endoscopy and reintroduction…Single foods are introduced every 5-7 days” within a group and then endoscopy after 3-4 foods are clinically tolerated.”  Foods from groups C and D are introduced more cautiously.

Also noted: HM Ko et al. Am J Gastroenterol 2014; 109: 1277-85.  This retrospective study of 30 children with severe gastric eosinophilia (mean age 7.5 years) provides a good deal of useful information.  Key point: “the disease is highly responsive to dietary restriction therapies.”  82% of patients responded to dietary restrictions and 78% had a histologic response as well.  Dietary treatments included amino acid-based diet in 6 (n=6), 7-food group empiric diet (n=6), and empiric avoidance of 1-3 foods (n=5).  Pharmacologic treatments (proton pump inhibitor or cromolyn) were attempted in a total of four patients in this series with half responding clinically and one of four responding histologically.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.