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Key Take-home Messages in EoE Care
The Role of NPs and PAs in the Timely Diagnosis and Management of EoE: Key Take-home Messages

Released: December 12, 2023

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Key Takeaways
  • The timely recognition and diagnosis of EoE, a chronic inflammatory condition, is imperative to help patients achieve treatment goals and avoid long-term esophageal damage.
  • It is important for healthcare professionals to help patients navigate potential EoE treatment barriers, such as cost, coverage, and adherence.
  • Every patient with EoE is unique, with varying clinical presentations and responses to treatment.

In this commentary, Amanda Michaud, DMSc, PA-C, AE-C, and Megan O. Lewis, MSN, RN, CPNP-PC, discuss the importance of increasing healthcare professional (HCP) awareness and recognition of eosinophilic esophagitis (EoE) in patients of all ages in the primary care setting, insights into the challenges related to traditional therapies and biologics, and how personalizing care can improve adherence and minimize exacerbations. 

Awareness and Recognition of EoE

Improving Diagnosis

Megan O. Lewis, MSN, RN, CPNP-PC:
In the primary care setting, when a patient complains of abdominal pain, there are many diagnoses to be considered. A child who is a picky eater or has difficulty eating is commonly seen in clinic, and keeping EoE on the radar as a potential diagnosis is important, especially if the child is male or has other atopic diseases, such as rhinitis, IgE-mediated food allergies, or asthma. 

In a patient who has had a choking episode, I would consider an EoE diagnosis and take the time to ask about eating habits. I think families often do things around the dinner table that they think are normal, but by asking more specific questions, you may find out, for example, that they take a long time to eat meals, they drink 4 glasses of water with their meals, they avoid certain foods, or they excessively chew their foods. These are signs that they have developed coping strategies for undiagnosed EoE.

Amanda Michaud, DMSc, PA-C, AE-C:
Many of our patients with EoE, including children and adults, will have maladaptive behaviors such as these, and this potentially will mask their EoE symptoms. Patients adapt to and attempt to reduce symptoms over time on their own without realizing that something was abnormal. I also often see parents who think that their young child who is a picky eater is just seeking attention. Awareness of maladaptive behaviors allows HCPs to recognize and diagnosis EoE early, potentially preventing complications of a delayed diagnosis such as stricture formation or narrowing of the esophagus.

I often use the phrase, “Dysphagia in someone with atopic conditions is EoE until proven otherwise.” We know that 23% of patients with dysphagia who undergo endoscopy are diagnosed with EoE. Therefore, when we see a patient who we know has seasonal allergic rhinitis, asthma, atopic dermatitis, or food allergy, with any prior choking episode, we should think it is EoE until we know it is not. Therefore, the patient should be referred to gastroenterology, and it is important to make sure the specialist the patient is seeing is aware that we are concerned about EoE.

Diagnostic Strategies

Megan O. Lewis, MSN, RN, CPNP-PC:
When we see patients in the allergy clinic who were referred by their primary care provider (PCP), they often have been prescribed a proton pump inhibitor (PPI) to alleviate symptoms, and in the past it was a diagnostic strategy for EoE. However, as of 2018, the updated EoE guidelines no longer require PPI therapy to establish an EoE diagnosis. Instead, PPIs are now considered a first-line treatment option alongside topical corticosteroids and dietary modifications.

Another key takeaway for diagnosing EoE is to collect a thorough family history. If a patient has family members with asthma, allergic rhinitis, and EoE, HCPs should be thinking about EoE. I frequently see young patients with EoE with parents, uncles, and other family members who go on to receive a diagnosis of their own after learning about the condition. Fortunately, we can connect them with an adult specialist to receive care.

Currently, a patient must have an upper endoscopy with biopsies of the esophagus to be diagnosed with EoE. Because of the invasive nature of this strategy, patients may not return for follow-up. There are new diagnostic modalities that do not involve an endoscopy with sedation, such as transnasal endoscopy, which has been successfully used in children and young adults to obtain esophageal biopsy specimens. A transnasal endoscopy involves passing a thin tube with a camera at one end through the nose. Because it does not require anesthesia, it can be completed in an outpatient setting. The esophageal string test is another less-invasive method to sample the esophagus whereby a string attached to a capsule is swallowed. The string stays outside of the mouth for easy removal. Inflammatory mediators are absorbed by the string, which then can be analyzed for markers of eosinophilic inflammation.

Therapeutic Challenges

Megan O. Lewis, MSN, RN, CPNP-PC:
Beyond PPIs, patients and families initially may think that the few treatment options available for EoE are unpleasant. However, it is important that HCPs discuss the long-term consequences of inadequately treated EoE with patients and how each treatment addresses goals of care. I think when we are giving treatment options, it is important to also give patients time to consider the pros and cons and discuss these with their PCPs. We are fortunate that biologic therapies for many allergic conditions have revolutionized care in the past 10 years, and this applies to EoE, as well. 

Elimination diets have been a longstanding treatment approach but often are challenging for patients, who may be asked to remove favorite foods from their diet. In addition, these have significant social and nutritional implications. Including a dietitian in the patient’s care is critical. It is also important to discuss treatments beyond diet adjustments, such as swallowed corticosteroids that may be ideal for patients who want to eat freely and not restrict their diet. Now, we also have the biologic dupilumab, which really has changed the treatment option landscape in EoE. Patients taking dupilumab feel better because of symptom resolution and better endoscopy results, and their families are excited, too.

Amanda Michaud, DMSc, PA-C, AE-C:
I think the biggest barrier to using biologics is cost and insurance coverage. Many times, we must go through several steps to get the medication approved, and sometimes trials of other types of medication modalities are required first. Some patients also may be hesitant to use an injectable agent. However, the improvements in quality of life provided by dupilumab vs significant dietary modifications can outweigh the concerns about the route of administration for many patients.

Because therapy options are a big discussion and those appointments can be overwhelming for patients and families, it can be helpful to give them time to consider the options, as they may not be able to make the best decision right then and there. I also like to remind patients and families that what they decide now may not work for them in a year or two. What works for a patient when they are 5 years old may not work when they are a busy teen involved in extracurricular activities and sports, when they go to college, or when they are adults. I let them know that we can shift gears and try combinations of these therapies, too. It is rare that we have patients receiving monotherapy, but both topical corticosteroids and dupilumab can be used in that way. I think the biggest barriers for any treatment are adherence and finding one that works best for the patient, maximizes their adherence, and improves their EoE.

It is important for PCPs to understand that the clinical symptoms of EoE do not necessarily correlate with histologic disease control. Often, the challenge in our practice is with follow-up, the need for repeat endoscopies, and adherence. We see patients who respond symptomatically, but they still have inflammation present in their esophageal biopsies, which if left untreated can result in issues down the road such as fibrostenosis and stricture formation, as well as possible need for repeat esophageal dilations.  

Personalizing EoE Care

Amanda Michaud, DMSc, PA-C, AE-C:
It is important to keep in mind that every patient with EoE is unique, with different presentations and variable responses to treatment. Throughout all of these stages, the HCP needs to meet the patient where they are and discuss their management options to provide all necessary information to make the best decision for their personal values and belief systems, and even sometimes their life and work schedule.

When we think of personalizing EoE care, HCPs should consider a patient’s comorbid conditions. Those with severe asthma, moderate to severe atopic dermatitis, or chronic rhinosinusitis with nasal polyps particularly may benefit from the use of dupilumab, which also treats those conditions. This can help minimize medication burden and exacerbations for those conditions, as well. 

I do not have a lot of patients who are highly motivated to undergo an extensive food elimination diet. Several years ago, we were recommending 6-food elimination for everybody with a repeat endoscope after every 1 or 2 foods were reintroduced. It was very difficult and challenging, but now we tailor our treatment, and I feel our options allow us to be less rigid in EoE management. However, if a patient is motivated to implement an elimination diet, this may reduce their need to use a medication. To assess their motivation, I ask if they are willing to avoid milk and wheat or just milk for the next couple of months. After that time, we can follow up with an endoscopy to measure improvement.

Often, the patient may prefer to try a PPI first, even though we know that only approximately 40% of people will have a complete response to a PPI. Many times in my practice, we will start a patient on a PPI or topical corticosteroids temporarily while they are considering their long-term treatment preferences.

Megan O. Lewis, MSN, RN, CPNP-PC:
Shared decision-making in EoE is essential for achieving disease- and patient-related clinical goals of symptom and endoscopic improvement. Some families may not care much about the number of eosinophils present in a high-powered field, so collaborating with them on the rationale for esophageal healing is key. Engaging with a registered dietitian can help with providing comprehensive treatment.

Finally, as we think about transitions of care for patients, involving adolescents or children in discussions—based on their developmental level—is important. If they do not want to remove milk, they are not going to do it, and clinical trials have taught us that there are many ways to sneak milk into the diet. Therefore, I think it is important to make sure that the patient’s desires are met, and agreement on a decision together with the family is foundational to care.

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