Challenges in managing patients referred for eosinophilic esophagitis: A telephone survey and retrospective review

Background: Eosinophilic esophagitis (EoE) in patients referred to allergists can be difficult to manage. This is due to multiple factors, including overlaps in presentation with gastroesophageal reflux disease and proton-pump inhibitor responsive eosinophilia, remaining uncertainties regarding the role of different forms of allergy testing, and a variety of patient adherence issues. Objective: To highlight, in an objectively studied fashion, complications that can be faced when managing patients referred for EoE. Methods: We conducted a telephone survey of 78 patients (pediatric and adult) who were referred to our academic allergy clinic for EoE. The survey focused on patients’ perspectives regarding their symptoms and treatments. We then conducted a chart review to determine if there had been a proton-pump inhibitor (PPI) trial before diagnosis, and we compared patient responses with documented allergy test results, treatment plans, and biopsy results. Results: Only 22 of 78 patients (28%) had a 8-week PPI trial before diagnosis and/or referral. There was considerable variability in the type of allergy testing done for patients, and how the results were used to guide therapy. More than one-third of the patients reported being on a different treatment regimen (PPI, swallowed steroid, and/or diet) than planned, and the majority of patients on dietary therapy reported being on a different diet than planned. Also, nearly half of the adult patients did not have follow-up biopsies done despite recommendations for this. Conclusion: We identified several challenges in EoE management, including potential misdiagnosis or overtreatment, lack of standardization in testing and dietary recommendations, and patient adherence issues. We hope this information will prompt increased vigilance for these issues and promote solutions when needed.