Facilitated reintroduction of eliminated eosinophilic esophagitis trigger foods with dupilumab

Eosinophilic esophagitis (EoE) is a chronic, type 2 inflammatory disease of the esophagus, characterized by infiltration of eosinophils and symptoms of esophageal dysfunction. EoE is often exacerbated by common trigger foods, such as milk, egg, soy, and wheat, and can be effectively treated by their removal from the diet without the need for life-long medication. As most patients have a single trigger food, recent studies have demonstrated comparable efficacy between the one-food elimination diet, and four- and six-food elimination diets. However, maintaining adherence to any food elimination diet can be challenging and result in reduced quality of life. Some patients seek a safe and effective treatment to allow reintroduction of trigger foods into their diet. Dupilumab is a monoclonal antibody that blocks interleukin (IL)-4 and IL-13 signaling pathways, which are key and central drivers of type 2 inflammation. In phase 3 trials, dupilumab improved histologic, endoscopic, symptomatic, and transcriptomic outcomes in patients with EoE. A recent pilot study investigated the facilitation of trigger food reintroduction with dupilumab in children with EoE, who initially received 3 months of dupilumab treatment to ensure EoE disease control, before gradually reintroducing trigger foods every 3 months with continued dupilumab treatment. Overall, 86% of instances of trigger food reintroduction were successful, without loss of histologic remission. Children were able to reintroduce trigger foods without any worsening in histologic, endoscopic, or symptomatic outcomes, or narrowing of the esophagus. While all children who completed the study were able to reintroduce at least one serving of trigger food, some lost histologic remission after an initial attempt of trigger food reintroduction but were able to successfully reintroduce trigger foods after continued dupilumab treatment. Other children were able to rapidly reintroduce trigger foods every 3 months. Further investigation is required to determine patient characteristics that may influence the rate at which trigger foods can be reintroduced. The most common adverse events were upper respiratory tract infections, followed by injection-site reactions. Dupilumab may provide an effective method to reduce dietary burden in patients with EoE. Results from an ongoing study investigating trigger food reintroduction with dupilumab in adults are anticipated.