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Month: June 2022

The Treatment of Eosinophilic Esophagitis

The esophagus is a tubal structure that propels food from the throat into the stomach through rhythmic contractions of the smooth muscles in its walls. A thin mucus membrane lines the insides of its lumen. Eosinophils are type of white blood cells that have some role in combating certain parasitic infections. Eosinophils can also cause damage to tissues when they are accumulated in excess, due to a chronic inflammatory process.

Eosinophilic esophagitis (EoE) is an allergic/immunologic disorder in which eosinophils cause dysfunction of the esophagus which then leads to a difficulty in swallowing and occasionally an impaction of foods. The exact cause of the eosinophilic esophagitis is not clearly established but genetic factors predispose to the disease process. More recent evidence points to an allergic sensitization to certain foods, and possibly to environmental allergens, playing a role in the pathogenesis of the disorder.

Eosinophilic esophagitis is a rare disease, as it is estimated that there are approximately 160,000 people suffering from it in the United States. Eosinophilic esophagitis can occur in all age groups; however, it is most common in men during their 20’s and 30’s. A history of various atopic conditions such as asthma, atopic dermatitis (i.e., eczema), seasonal allergies (i.e., allergic rhinitis, hay fever), and food allergies may also be present in these individuals.

The symptoms of eosinophilic esophagitis usually include difficulty in swallowing, heartburn, abdominal pain or discomfort, and/or a bloating sensation. Many patients are diagnosed after an emergency department visit for the management of food getting “stuck” in the esophagus. The condition has a chronic remitting and relapsing course and many patients suffer from symptoms for many years before getting properly diagnosed.

The diagnosis of eosinophilic esophagitis is suspected by detecting ridges, furrows, rings, and strictures within the esophagus when observed via an upper endoscopic procedure. These sequelae are a result of the chronic inflammatory damage to the esophagus. The demonstration of an excessive accumulation of eosinophils (i.e., greater than or equal to 15 eosinophils per high power field) in the lining of the esophagus by microscopic examination of a biopsy specimen is required for the confirmation of the diagnosis.

Until recently, there have been no specific treatment options for the management of eosinophilic esophagitis. Some patients respond to empiric treatment with proton pump inhibitor (PPI) medications [i.e., Prilosec (omeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole)] which reduce the acid secretion in the stomach and minimize reflux into esophagus.

An empiric 6 food elimination diet with milk, wheat, peanut/tree nut, egg, soy, and seafood/shellfish may be helpful in some individuals. The avoidance of specific foods based on a skin testing procedure to detect allergic sensitization may also be beneficial in minimizing symptoms in some patients. Others may require a more elemental amino-acid based diet to help control their unwanted symptoms.

The next step in the management of eosinophilic esophagitis is to utilize topical corticosteroids in order to control the inflammation inside the esophagus. Corticosteroid medications such as fluticasone and budesonide which were originally indicated for asthma are used in an ingested form in order to coat the interior mucosal surface of the esophagus. In this approach, the asthma inhaler is swallowed instead of inhaled in order to apply the anti-inflammatory corticosteroid medication directly to the desired tissue (i.e., esophagus). Despite this approach, however, many patients can continue to be symptomatic.

Recent advances in the understanding of the underlying pathologic process now focuses on the role of cytokines (i.e., molecules that mediate and drive the inflammatory process) such as interleukin-13 (IL-13). Clinical trials have shown that blocking these molecules by therapeutic agents may result in the improvement in the structural appearance of the esophagus, reduce the numbers of eosinophils in the esophagus, and thus bring about resolution of many of the symptoms of eosinophilic esophagitis.

Recently (on 5/20/2022), the U.S. Food and Drug Administration (FDA) approved Dupixent (i.e., dupilumab) as a treatment for eosinophilic esophagitis in adults and pediatric patients 12 years and older weighing at least 40 kilograms (i.e., 88 pounds). Dupixent is a monoclonal antibody and “biological” medication that acts to inhibit part of the inflammatory pathway.

Dupixent was originally approved in 2017 for anther condition. It is currently approved for the treatment of moderate to severe atopic dermatitis (i.e., eczema) in adult and pediatric patients aged 6 and older whose disease is not adequately controlled by topical prescription therapies or when those therapies are not advisable. Dupixent is also approved as an add-on maintenance treatment for adults and pediatric patients aged 6 and older with certain types of moderate to severe asthma, as well as an add-on maintenance treatment in adults with inadequately controlled chronic rhinosinusitis with nasal polyposis.

The dose of Dupixent for eosinophilic esophagitis is a 300 mg. injection under the skin once every week. Most patients can self-inject with a pre-filled syringe either over the abdomen or thighs. The most common side effects associated with Dupixent include injection site reactions, upper respiratory tract infections, joint pain, and herpes viral infections.

Undoubtedly there will be other treatments for eosinophilic esophagitis in the future. Until these remedies become available, we currently do have good therapeutic options that should curtail or prevent the symptoms of eosinophilic esophagitis.

The board certified allergists/immunologists at Black & Kletz Allergy can answer your questions and address your concerns you have regarding eosinophilic esophagitis or any other type of eosinophilic disorder. In addition, we treat a variety of allergic diseases including allergic rhinitis (i.e., hay fever), asthma, sinus conditions, hives, (i.e., urticaria), food allergies, medication allergies, insect sting allergies, and immunological disorders. We have been serving the Washington, DC, Northern Virginia, Maryland metropolitan area for over 50 years. Our office locations are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer parking at each office location and we are Metro accessible at our Washington, DC and McLean, VA locations. We also offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Please call us at one of our locations to schedule an appointment or you can click Request an Appointment on our website and we will respond to you within 24 hours by the next business day.

Generalized Pruritus (Itching)

Generalized pruritus (i.e., generalized itching) is not an uncommon condition and can be quite maddening to the individual suffering from it. It may be associated with hives (i.e., urticaria) and/or angioedema (swelling). The itching is usually described as either intermittent or chronic itching in various parts of the body or it can be intermittent or chronic itching of the entire body. In some individuals, the itching only lasts for a couple of days. In other individuals however, the itching can last much longer. It is not atypical for the itching to lasts weeks, months, or in some cases, years. The severity of the itching can be anywhere from mild to very severe. Many pruritus sufferers complain that the itching is so bothersome that it affects their quality of life. Regardless of how severe the itching is, one should seek medical care from a board certified allergist, like the ones at Black & Kletz Allergy, if the itching has occurred for more than 6 weeks so that the cause of the itching can be explored and hopefully identified. Pruritus is also generally easier to treat if the cause of the itching has been identified.

The diagnosis of pruritus is based solely on what the individual tells the allergist during a comprehensive history and physical examination. It is however important for the allergist to try to identify a cause of the itching as there are many known causes of pruritus. If the itching has been present for less than 6 weeks, the pruritus is said to be “acute.” Most of the time with acute pruritus, no testing is needed and the patient is treated with medications to alleviate the itching. In instances of “chronic” pruritus, where the itching has been present for more than 6 weeks, allergy tests and/or blood tests may be indicated in order to try to find the cause of the itching.

Some of the more common causes of pruritus may include food allergies, medication allergies, iron deficiency anemia, hepatitis B, hepatitis C, thyroid disease, chronic lymphocytic leukemia (CLL), diabetes mellitus, lung cancer, uremia (i.e., kidney damage), xerosis (i.e., dry skin), and pregnancy. It is important that a cause be identified so that either the allergen is avoided or treatment can be directed at the underlying systemic condition responsible for the itching.

The treatment of pruritus is always aimed at treating the underlying condition responsible for the itching. For example, if an individual is found to have hypothyroidism as the cause for the itching, it is prudent to treat the thyroid disease and the itching should go away. If no identifiable cause can be detected; the treatment then is aimed at alleviating the itching itself. There are a variety of medications that can be utilized in order to treat the itching. Some of these medications may include antihistamines [e.g., Benadryl (diphenhydramine), Atarax (hydroxyzine), Claritin (loratadine), Allergra (fexofenadine), Zyrtec (cetirizine), Xyzal (levocetirizine), Clarinex (desloratadine)], H2 blockers [e.g., Pepcid (famotidine), Tagamet (cimetidine)], and leukotriene antagonists [e.g., Singulair (monteleukast)]. Rarely, oral corticosteroids may be used for refractory cases. Topical ointments and/or creams have also been used with some success in certain patients.  The length of time that a patient needs to be treated varies greatly from individual to individual.  In the majority of cases, medications may only be needed for 1 or 2 weeks, but can be necessary is some patients for several years.  Other treatments such as UV light treatments have been used with varying degrees of success.

The board certified allergy specialists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. The allergy doctors at Black & Kletz Allergy are extremely knowledgeable regarding generalized pruritus as well as other skin disorders such as hives, eczema (i.e., atopic dermatitis), and swelling episodes. We diagnose and treat both pediatric and adult patients. In addition, we treat patients with environmental allergies, medication allergies, insect sting allergies, asthma, sinus disease, eosinophilic conditions, and immunological disorders. To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day. We have been servicing the greater Washington, DC area for more than 5 decades and we look forward to providing you with first-rate state-of-the-art allergy care in a welcoming and professional environment.