Allergy, Asthma CE/CME ACCREDITED Watch Time: 30 mins

touchEXPERT OPINIONS What’s new for eosinophilic oesophagitis? A case-based discussion of patient care

Watch experts give their perspective on different aspects of managing patients with EoE, based on clinical case studies.

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Dr Stuart Carr
Snö Asthma & Allergy Clinic, Abu Dhabi, UAE
Exploring the pathophysiology and clinical manifestations of EoE

Dr Stuart Carr provides his perspective on the latest understanding of the aetiology, pathophysiology and clinical manifestations of EoE.

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In this interview, Dr Carr answers the following questions:

  • What is the latest understanding of the different environmental and genetic factors associated with EoE development?
  • What is the role of T helper type 2 cells in EoE and is EoE associated with any other type-2 inflammatory diseases?
  • What is the latest understanding regarding the role of milk and IgG4 in EoE?
  • How does the pathophysiology of EoE manifest clinically in terms of what is seen during endoscopy or in biopsy samples?

Stuart Carr, MD FRCPC FAAAAI, is chief medical officer at Snö Asthma & Allergy Clinic in Abu Dhabi, UAE. read more

Previously, Dr Carr was associate clinical professor at the University of Alberta, and he was past-president of the Canadian Society of Allergy and Clinical Immunology (CSACI). He currently serves as a reviewer for Allergy, Asthma & Clinical Immunology, the journal of the CSACI.

Dr Carr’s primary interests are paediatric asthma, food allergy and eosinophilic oesophagitis. Dr Carr is currently involved in a Canadian-wide collaboration examining the safety and effectiveness of oral immunotherapy for peanut and other food allergies in preschool children.

Dr Stuart Carr discloses Advisory board/panel fees from Sanofi/Genzyme. Consultancy fees from Aralez Canada. Speaker’s bureau fees from Sanofi/Genzyme.

 
Dr Mário Vieira
Hospital Pequeno Príncipe, Curitiba, PR, Brazil
Managing EoE: Diagnosis and treatment of paediatric patients

Dr Mário Vieira provides his perspective on the diagnosis and management of paediatric patients with EoE, based on an example patient case.

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In this interview, Dr Vieira answers the following questions:

  • Please could you introduce the patient case?
  • Are this patient’s symptoms typical of how EoE presents in children of any age?
  • What are the current choices for first and subsequent lines of treatment for children with EoE?
  • What is the potential for biological therapies in children based on the current and emerging data?
  • How can we monitor disease activity and treatment response in patients with EoE?
  • Thinking back to our patient case, how would you treat and monitor disease activity for this child?

Dr Mário C Vieira, MD MSc PhD, is head of the Division of Pediatric Gastroenterology and Gastrointestinal Endoscopy at Hospital Pequeno Príncipe, Curitiba, Brazil. read more

Dr Vieira trained in Brazil and at St. Bartholomew’s Hospital, London, UK, and set up a paediatric gastroenterology unit at Hospital Pequeno Príncipe (a 380-bed paediatric teaching hospital), Curitiba, Brazil, in 1994. 

Dr Vieira runs a busy practice-based referral unit involving different aspects of paediatric gastroenterology and gastrointestinal endoscopy.

Dr Mário Vieira discloses Advisory board/panel fees from Danone Nutricia. Speaker’s bureau fees from Aché Laboratories, Danone Nutricia and Nestlé Nutrition.

 
Prof. Arjan Bredenoord
Amsterdam University Medical Center, Amsterdam, Netherlands
Managing EoE: Diagnosis and treatment of adult patients

Prof. Arjan Bredenoord provides his perspective on the diagnosis and management of adult patients with EoE, based on an example patient case.

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In this interview, Prof. Bredenoord answers the following questions:

  • Please could you introduce the patient case?
  • Which differential diagnoses might you consider for this patient and how might you confirm the diagnosis?
  • What are the current treatment options for this patient and how effective are they?
  • What are the emerging biologic treatment options for patients with EoE and what do the data tell us?
  • How can we monitor treatment outcomes and disease progression in this patient and generally in adult patients with EoE?

Arjan Bredenoord, MD, is consultant gastroenterologist at the Amsterdam University Medical Center (AMC), and professor of neurogastroenterology and motility at the University of Amsterdam in the Netherlands. read more

In his current work as a consultant gastroenterologist, Prof. Bredenoord is dedicated to patient care, scientific research and education in the field of benign oesophageal diseases. Prof. Bredenoord’s main focus is on achalasia, reflux disease and eosinophilic oesophagitis. He is one of the pioneers of high-resolution manometry and impedance monitoring of the oesophagus. The oesophageal clinic at the AMC hosts the largest population of benign oesophageal diseases in the Netherlands. 

Prof. Bredenoord is an author of over 250 articles, books and book chapters. He organizes regular courses in Europe, North America and Asia. He is past president of the European Society of Eosinophilic Esophagitis (EUREOS), member of the United European Gastroenterology (UEG) Scientific Committee, and co-founder of the International High-Resolution Manometry (HRM) working group.

Prof. Arjan Bredenoord discloses Advisory board/panel fees from Alimentiv, Arena Pharmaceuticals Inc., AstraZeneca, Calypso Biotech, Dr. Falk Pharma, EsoCap, Laborie, Medtronic, Reckitt, Regeneron Pharmaceuticals Inc. and Sanofi. Consultancy fees from Alimentiv, Arena Pharmaceuticals Inc., AstraZeneca, Calypso Biotech, Dr. Falk Pharma, EsoCap, Laborie, Medtronic, Reckitt, Regeneron Pharmaceuticals Inc. and Sanofi. Grants/research support from Nutricia and Thelial; Bayer, Dr. Falk Pharma, Gossamer Bio, Norgine and SST (relationships terminated). Speaker’s bureau fees from AstraZeneca, Dr. Falk Pharma, Laborie, Medtronic, Regeneron Pharmaceuticals Inc. and Sanofi.

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Learning Objectives & Overview
Overview

In this activity, international experts discuss the latest understanding of eosinophilic oesophagitis (EoE) pathophysiology, how to differentiate EoE from gastro-oesophageal reflux disease, and current and future treatment and monitoring options for patients with EoE.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of adult and paediatric gastroenterologists, adult and paediatric allergists/immunologists, paediatricians, advanced nurse practitioners, physician assistants and practice nurses involved in the management of patients with eosinophilic oesophagitis.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity.  The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Stuart Carr discloses: Advisory board/panel fees from Sanofi/Genzyme. Consultancy fees from Aralez Canada. Speaker’s bureau fees from Sanofi/Genzyme. 

Dr Mário Vieira discloses: Advisory board/panel fees from Danone Nutricia. Speaker’s bureau fees from Aché Laboratories, Danone Nutricia, Nestlé Nutrition.

Prof. Arjan Bredenoord discloses: Advisory board/panel fees from Alimentiv, Arena Pharmaceuticals Inc., AstraZeneca, Calypso Biotech, Dr. Falk Pharma, EsoCap, Laborie, Medtronic, Reckitt, Regeneron Pharmaceuticals Inc. and Sanofi. Consultancy fees from Alimentiv, Arena Pharmaceuticals Inc., AstraZeneca, Calypso Biotech, Dr. Falk Pharma, EsoCap, Laborie, Medtronic, Reckitt, Regeneron Pharmaceuticals Inc. and Sanofi. Grants/research support from Nutricia and Thelial; Bayer, Dr. Falk Pharma, Gossamer Bio, Norgine and SST (relationships terminated). Speaker’s bureau fees from AstraZeneca, Dr. Falk Pharma, Laborie, Medtronic, Regeneron Pharmaceuticals Inc. and Sanofi.

Content reviewer

John Jacobs MD has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Directors

Anne Nunn and Kathy Day have no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu.

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 18 August 2022. Date credits expire: 18 August 2023.

If you have any questions regarding credit please contact cpdsupport@usf.edu.

Learning Objectives

After watching this activity, participants should be better able to:

  • Describe the complex pathophysiology of EoE and how this manifests as clinical symptoms throughout life
  • Distinguish eosinophilic oesophagitis as a progressive disease that is distinct from GORD
  • Summarize the clinical evidence supporting the use of emerging biologic treatments for EoE
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Question 1/5
Your 23-year-old patient attends a clinic visit following a diagnosis of EoE. She also has comorbid asthma and a peanut allergy. During discussions, your patient asks what caused her EoE to occur. What would you do?

EoE, eosinophilic oesophagitis; Ig, immunoglobulin.
Correct

Although food can be a trigger for EoE, the mechanism is not IgE mediated.1 Skin prick, atopy patch and food-specific IgE testing results do not reliably identify causative foods in most patients with EoE.1,2 Higher food-specific IgG4 levels have been observed in patients with active EoE compared with those in remission, patients with GORD, and healthy controls without EoE or GORD; however, the exact role of IgG4 in EoE is yet to be determined.3–6 This limits current clinical application of food-specific IgG4 testing. The most common approach to identifying food triggers for EoE in practice is dietary elimination.2

Abbreviations

EoE, eosinophilic oesophagitis; GORD, gastro-oesophageal reflux disease; Ig, immunoglobulin.

References

  1. Simon D, et al. Allergy. 2016;71:611–20.
  2. Attwood SE. Br J Hosp Med (Lond). 2019;80:132–8.
  3. Masuda M, et al. J Allergy Clin Immunol. 2022;149(Suppl.):AB210. 
  4. Erwin E, et al. J Allergy Clin Immunol. 2022;149(Suppl.):AB209. 
  5. Li R-C, et al. J Allergy Clin Immunol. 2022;149(Suppl.):AB201.
  6. Khan S, et al. Digestion. 2021;102:342–56.
Question 2/5
Your 27-year-old patient was diagnosed with EoE after experiencing food impaction. He initially tried proton pump inhibitor therapy, but was unresponsive. Together, you decide he will try swallowed topical corticosteroids. While explaining how to take this treatment, you emphasize the importance of adherence. Your patient asks what will happen if he does not take his medication as advised. Which is the most appropriate response to their question?

EoE, eosinophilic oesophagitis.
Correct

EoE is a chronic, progressive ‘type 2’ inflammatory condition.1 Underlying inflammation drives oesophageal remodelling and barrier dysfunction, resulting in fibrosis, stricture formation and oesophageal narrowing.1,2 Consequently, functional abnormalities, such as dysphagia and food impaction, may arise.1,3

Abbreviation

EoE, eosinophilic oesophagitis.

References

  1. Racca F, et al. Front Physiol. 2022;12:815842.
Question 3/5
Your 13-year-old patient has been experiencing heartburn, abdominal pain and occasional vomiting after food intake for the past 6 months. Over the past few weeks, these symptoms have become a daily occurrence. Your patient’s medical records state a history of asthma. You suspect an underlying diagnosis of GORD or EoE. What would you do next?

EoE, eosinophilic esophagitis; GORD, gastro-oesophageal reflux disease.
Correct

Endoscopy with oesophageal biopsy is considered the gold-standard procedure for confirming an EoE diagnosis.1,2 The majority of patients with GORD have normal findings or reflux oesophagitis on endoscopy, whereas those with EoE commonly have other signs, such as oedema, rings and exudates.3 Some patients with EoE, particularly children, may have a macroscopically normal appearance on endoscopy.2,3 As such, guidelines recommend taking oesophageal biopsies to confirm a diagnosis.2,4 A peak eosinophil count of ≥15 eos/hpf is required for diagnosis of EoE; GORD is typically associated with <5 eos/hpf.2–4

Abbreviation

EoE, eosinophilic oesophagitis; eos/hpf, eosinophils per high power field; GORD, gastro-oesophageal reflux disease.

References

  1. Barni S, et al. Ital J Pediatr. 2021;47:230.
  2. Dhar A, et al. Gut. 2022;71:1459–87.
  3. Attwood SE. Br J Hosp Med (Lond). 2019;80:132–8.
  4. Lucendo AJ, et al. United European Gastroenterol J. 2017;5:335–58.
Question 4/5
GORD is a key differential diagnosis for EoE. Which of the following factors could help to distinguish EoE from GORD?

EoE, eosinophilic oesophagitis; GORD, gastroesophageal reflux disease.
Correct

Food impaction is a common complication of EoE, but is not typically associated with GORD.

Abbreviations

EoE, eosinophilic oesophagitis; GORD, gastroesophageal reflux disease.

Reference

Attwood SE. Br J Hosp Med (Lond). 2019;80:132–8.

Question 5/5
Siglec-8 is found on the surface of immune cells involved in the pathophysiology of EoE, including mast cells and eosinophils. Which of the following agents, currently in development, targets Siglec-8?

EoE, eosinophilic oesophagitis; Siglec-8, sialic acid-binding immunoglobulin-type lectin
Correct

Lirentelimab is a humanized monoclonal antibody that targets Siglec-8.1 In a phase II/III trial of high- or low-dose lirentelimab vs PBO in patients with EoE (N=276), 88% and 93% of those in the low- and high-dose groups, respectively, achieved a histologic response (≤6 eos/hpf) vs 11% of those in the PBO group (p<0.001).2 However, there was no significant difference in Dysphagia Symptom Questionnaire scores between groups.2 Lirentelimab continues to be studied in other patient populations, such as those with chronic spontaneous urticaria (NCT03436797), eosinophilic gastritis and/or eosinophilic duodenitis (NCT04620811, NCT05152563) and atopic dermatitis (NCT05155085).3,4

Abbreviation

EoE, eosinophilic oesophagitis; eos/hpf, eosinophils per high power field; PBO, placebo; Siglec-8, sialic acid-binding immunoglobulin-type lectin.

Reference

  1. Racca F, et al. Front Physiol. 2022;12:815842.
  2. Dellon ES, Spergel JM. Ann Allergy Asthma Immunol. 2022;S1081-1206:00536-1.
  3. Altrichter S, et al. J Allergy Clin Immunol. 2022;149:1683–1690.e7.
  4. ClinicalTrials.gov. Available at: www.clinicaltrials.gov/ct2/ (accessed 27 July 2022).
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