New-onset IgE mediated reactions in eosinophilic esophagitis associated elimination diets (NIMREEDs)

Empiric elimination diets remain a cornerstone of treatment for eosinophilic esophagitis (EoE). Immunoglobulin E (IgE) mediated allergic reactions have been sparsely reported during the food reintroduction phase, raising concerns both for patients and physicians. We aimed to assess the physician reported rates of new-onset IgE mediated reactions in EoE associated elimination diets (NIMREEDs), physician awareness of NIMREEDs, and how awareness impacts physician and patient treatment selection.

An international REDCap based questionnaire was distributed via interest groups, gastroenterologist server lists, and professional societies. Physicians were asked about their personal awareness and experience with NIMREEDs and how their knowledge affects physician and patient treatment decisions when contemplating elimination diets (ED) for treatment of EoE.

Between January and July 2023, 145 responses were included in this analysis. Of the 12,698 patients with EoE cared for in all responding centers, 4903 (38.6%) had attempted ED. NIMREEDs were reported in 43/4903 (0.88% [95% CI 0.5-1.2%]). Ninety-six (66.2%) physicians were aware of potential reactions, however only 71/96 (73.9%) discussed them with patients. Knowledge of NIMREEDs deter 17/96 (17.7%) physicians from recommending ED for EoE, and 15/71 (21.1%) of those who informed patients, reported reluctance of patients to undertake ED.

NIMREEDs following food re-introduction in the treatment of EoE are uncommon, nevertheless they are not widely recognized by physicians. Knowledge concerning NIMREEDs may affect both patient and physician treatment decisions and preferences, as they have potential to negatively affect quality of life, emphasizing the need for increased awareness to NIMREEDs in EoE patients.