Can a dairy-free and gluten-free diet treat Eosinophilic Esophagitis (EE)?

From the Guidelines

A dairy-free and gluten-free diet can be considered as part of the treatment for eosinophilic esophagitis (EoE), but it should be managed by a multiprofessional team and reserved for patients who fail monotherapy or have specific indications for dietary management. The British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines recommend that dietary management of EoE should be individualized and guided by a specialist dietitian, with a focus on eliminating common food allergens that may trigger the inflammatory response characteristic of EoE 1.

Key Considerations

• The guidelines suggest that combining elimination diets with pharmacological treatment is not routinely recommended, but can be considered in cases of treatment failure 1.
• A small paediatric retrospective study found that histological remission rates for swallowed steroids versus allergy-test directed diets versus both therapies were 50%, 60%, and 80%, respectively 1.
• The guidelines recommend commencing treatment in patients with EoE with a single modality therapy of either diet or pharmacotherapy, with combination therapy reserved for selected patients who fail monotherapy 1.

Dietary Management

• Allergy testing to foods (skin prick, specific IgE, patch testing) is not recommended for choosing the type of dietary restriction therapy for eosinophilic oesophagitis, as it has been found to be no more effective than empirical dietary elimination 1.
• Exclusive elemental diets have a limited role in eosinophilic oesophagitis, with high efficacy but low concordance rates, and should be reserved for patients refractory to other treatments 1.
• A dairy-free and gluten-free diet may be considered as part of the treatment, but it is essential to ensure nutritional adequacy while following this restricted diet, and a registered dietitian with experience in EoE can help with this 1.

Monitoring and Follow-up

• Patients undergoing dietary management for EoE should be closely monitored by a multiprofessional team, including a specialist dietitian, to assess response and make adjustments to the treatment plan as needed 1.
• Repeat endoscopy with biopsies is typically used to assess response to treatment, and foods can be systematically reintroduced one at a time to identify specific triggers 1.

From the Research

Eosinophilic Esophagitis Treatment

• Eosinophilic esophagitis (EoE) is a unique form of non-immunoglobulin E-mediated food allergy, characterized by esophageal eosinophil-predominant inflammation and dysfunction 2.
• The most common food allergens that trigger the disease are dairy/milk, wheat/gluten, egg, soy/legumes, and seafood 2.

Dietary Management

• Avoidance of trigger foods remains the only option targeting the cause, and not the effect, of the disease 2.
• Dietary therapy offers a long-term, drug-free alternative to patients who wish to remain off drugs and still be in remission 2.
• A dairy-free diet (DFD) and the 6-Food Elimination Diet (SFED) are effective first-line therapies for EoE 3.
• The response rate for DFD was 56.9% and for SFED was 52.0% 3.

Gluten-Free Diet

• Wheat, barley, and rye proteins (including gluten) may trigger EoE as a result of cross-reaction and/or cross-contamination with wheat 4.
• Some clinicians suggest that barley and rye might also trigger EoE and should be avoided in a 6-food elimination diet 4.
• However, there is no clear evidence that a gluten-free diet is necessary for all patients with EoE, and the decision to avoid gluten should be made on an individual basis 4.

Combination Therapy

• Concomitant therapy with proton pump inhibitors (PPIs) may be helpful in patients treated with a dairy-free diet 3.
• Topical corticosteroids and elimination diets are current treatment modalities for confirmed EoE, and the use of PPIs is being suggested as a potential regimen to treat EoE 5.