Outcomes of Serum Food-Specific Immunoglobulin G 4 to Guide Elimination Diet in Patients With Eosinophilic Esophagitis.

2024-02-01
The American journal of gastroenterology 119(6)
- Amanda Huoy Wen Lim
- Benjamin Ngoi
- Griffith B Perkins
- Stephanie Wong
- Gail Whitelock
- Plinio Hurtado
- Andrew Ruszkiewicz
- Thanh-Thao Adriana Le
- Pravin Hissaria
- Nam Quoc Nguyen

PubMed: 38299582
DOI: 10.14309/ajg.0000000000002678

Study Design

Type: Clinical Trial
Population: 22 patients with active EoE and 13 controls
Methods: prospective, controlled, single tertiary center trial; serum FS-IgG4 titers, esophageal eosinophil counts, and dysphagia symptom questionnaire scores were assessed; participants with elevated FS-IgG4 commenced 6-week targeted elimination diet; repeat serum FS-IgG4 and endoscopic and histologic examination at 6-week follow-up
Duration: 6-week
Funding: Unclear

Introduction

Eosinophilic esophagitis (EoE) is associated with atopy; however, recent studies have identified an association with food-specific immunoglobulin G 4 (FS-IgG 4 ) rather than immunoglobulin E antibodies. This study aimed to evaluate the role of serum FS-IgG 4 in guiding an elimination diet and its outcomes.

Methods

Patients with and without EoE were enrolled in a prospective, controlled, single tertiary center trial. Serum FS-IgG 4 titers, esophageal eosinophil counts, and dysphagia symptom questionnaire scores were assessed, and participants with elevated FS-IgG 4 (ImmunoCAP, cutoff of 10 mgA/L) commenced 6-week targeted elimination diet. Repeat serum FS-IgG 4 and endoscopic and histologic examination were performed at 6-week follow-up.

Results

Twenty-two patients with active EoE and 13 controls were recruited. Serum FS-IgG 4 to milk, wheat, soy, eggs, and nuts was significantly higher in EoE ( P = 0.0002, P = 0.002, P = 0.003, P = 0.012, and P < 0.001, respectively). Elevated serum FS-IgG 4 to 1 or more food groups (median 2) was identified in 21/22 (95.4%) patients with EoE; 20/21 underwent 6-week dietary elimination. Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 ( P = 0.0007) and 1 ( P = 0.002), respectively. Nine (45%) patients had histological remission (<15 eosinophils per high-power field). Fall in median esophageal eosinophil count was not statistically significant (50 vs 23; P = 0.068). Serum FS-IgG 4 did not decline by 6-week follow-up.

Discussion

Serum FS-IgG 4 to milk, wheat, soy, egg, and nuts was present at higher levels in EoE, with targeted elimination resulting in 45% histologic remission rate. Serum FS-IgG 4 has potential as a noninvasive biomarker in EoE. When successful, FS-IgG 4 -led elimination diet can negate need for medications and be viewed more favorably by patients because of its smaller endoscopic burden compared with empirical elimination diets.

Research Insights

Milk→Achieved Histological Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Milk→Reduced Dysphagia
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Large
Dose
targeted elimination
Milk→Reduced Dysphagia Symptom Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination
Milk→Reduced EoE Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Milk→Reduced Eosinophilic Esophagitis Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Milk→Reduced Esophageal Eosinophil Count
Fall in median esophageal eosinophil count was not statistically significant (50 vs 23; P = 0.068).
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Milk→Reduced Food-Specific Immunoglobulin G4 Level
Serum FS-IgG4 did not decline by 6-week follow-up.
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Milk→Reduced Histologic Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination
Soy→Achieved Histological Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Soy→Reduced Dysphagia
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Large
Dose
targeted elimination
Soy→Reduced Dysphagia Symptom Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination
Soy→Reduced EoE Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Soy→Reduced Eosinophilic Esophagitis Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Soy→Reduced Esophageal Eosinophil Count
Fall in median esophageal eosinophil count was not statistically significant (50 vs 23; P = 0.068).
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Soy→Reduced Food-Specific Immunoglobulin G4 Level
Serum FS-IgG4 did not decline by 6-week follow-up.
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Soy→Reduced Histologic Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination
Wheat→Achieved Histological Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Wheat→Reduced Dysphagia
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Large
Dose
targeted elimination
Wheat→Reduced Dysphagia Symptom Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination
Wheat→Reduced EoE Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Wheat→Reduced Eosinophilic Esophagitis Endoscopic Reference Score
Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 (P = 0.0007) and 1 (P = 0.002), respectively.
Effect
Beneficial
Effect size
Small
Dose
targeted elimination
Wheat→Reduced Esophageal Eosinophil Count
Fall in median esophageal eosinophil count was not statistically significant (50 vs 23; P = 0.068).
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Wheat→Reduced Food-Specific Immunoglobulin G4 Level
Serum FS-IgG4 did not decline by 6-week follow-up.
Effect
Neutral
Effect size
Small
Dose
targeted elimination
Wheat→Reduced Histologic Remission
Nine (45%) patients had histological remission (<15 eosinophils per high-power field).
Effect
Beneficial
Effect size
Moderate
Dose
targeted elimination