An allergen-specific immune signature-directed diet vs sham diet for treatment of eosinophilic esophagitis: A pilot-feasibility study

过敏原特异性免疫信号导向饮食与假饮食治疗嗜酸性粒细胞增多症的比较 食管炎：一项初步可行性研究 摘要 嗜酸性食管炎(EoE)是一种慢性疾病，定义为嗜酸性粒细胞异常渗入食管壁。 食道粘膜，导致吞咽困难、进行性食道狭窄和食物嵌塞。这个 发病率和患病率正在急剧上升，EoE现在是上消化道的一个主要原因 发病率。由于EoE是由过敏原介导并由食物触发的，饮食消除是主要的非 药物治疗。然而，消除饮食的方法是次优的、繁重的和耗时的。 在消费。目前可用的血液或皮肤过敏测试不能可靠地确定EoE的食物触发因素， 因此，必须根据经验将多种食物从饮食中移除。坚持这些限制性饮食是很困难的， 同样的方法也适用于所有患者，没有被排除的食物可能仍然是诱因。多重 需要内窥镜来识别触发因素，而这些侵入性和昂贵的程序存在风险。两大 必须解决一些问题，以便在EoE中广泛应用饮食疗法。首先，如果过敏反应准确 测试是可用的，治疗可以个性化和简化。食物很可能是一种 个别患者可以被淘汰，不太可能引发嗜酸性炎症的食物可能是 保留。第二，如果非侵入性生物标记物可用于监测治疗反应，则有必要 内窥镜检查可以大大减少。为了开始解决这两个主要的知识差距，我们开发了一个 新的过敏原特异性免疫信号，以指导饮食消除。这项技术可以预测食物的诱因 基于食道活检组织中食物特异性IgG4水平和外周血中CD4+T细胞刺激试验 血。在最初的测试中，这种方法比传统的基于皮肤的过敏测试更准确。我们有 还发现了一种很有前途的生物标记物，嗜酸性粒细胞过氧化物酶(EPX)，可以在血清和 追踪食道活检所测量的治疗反应。拟议的研究已经设计好了 对PAS 20-160做出高度响应，这是一种新的“小型R01”机制，鼓励临床试验/可行性 为更大规模的试验奠定基础的试验。为了生成关键数据来估计影响大小，我们将进行一项 过敏原特异性免疫信号导向饮食消除与假饮食的试点随机临床试验 消除的具体目标如下：1)评估过敏原特异性免疫标记的影响- 直接饮食消除与假消除对食道嗜酸性粒细胞计数和症状的影响 EoE患者的吞咽困难；2)评估血清EPX作为一种非侵入性生物标志物并评估其疗效 用于监测EoE患者饮食排除治疗反应的大小。这项创新的试验/可行 试验将由现有的多学科团队进行，该团队在EoE、临床试验、食品 过敏症、病理学和转化学。它最终将对治疗产生重大的临床影响。 通过个体化饮食消除和简化饮食消除监测来监测EoE 使用非侵入性生物标志物，因此患者可以避免经验性饮食消除的时间、精力和风险。

An allergen-specific immune signature-directed diet vs sham diet for treatment of eosinophilic esophagitis: A pilot-feasibility study ABSTRACT Eosinophilic esophagitis (EoE) is a chronic disease defined by abnormal infiltration of eosinophils into the esophageal mucosa, leading to dysphagia, progressive esophageal stenosis, and food impaction. The incidence and prevalence are rising dramatically, and EoE is now a major cause of upper gastrointestinal morbidity. Because EoE is allergen-mediated and triggered by foods, dietary elimination is the primary non- pharmacologic treatment. However, the approach to dietary elimination is sub-optimal, burdensome, and time- consuming. Currently available blood- or skin-based allergy tests do not reliably identify food triggers of EoE, so multiple foods must be empirically removed from the diet. Adherence to these restrictive diets is difficult, the same approach is used for all patients, and foods that are not eliminated may still be triggers. Multiple endoscopies are required to identify triggers, and these invasive and costly procedures carry risks. Two major issues must be addressed to allow widespread application of dietary therapy in EoE. First, if accurate allergy tests were available, treatment could be personalized and streamlined. Foods likely to be triggers in an individual patient could be eliminated, and foods unlikely to provoke eosinophilic inflammation could be retained. Second, if non-invasive biomarkers were available to monitor treatment response, the need for endoscopies could be greatly reduced. To begin to address these two major knowledge gaps, we developed a novel allergen-specific immune signature to guide dietary elimination. This technique predicts food triggers based on food-specific IgG4 levels in esophageal biopsies and CD4+ T-cell stimulation assays in peripheral blood. In initial testing, this approach was more accurate than traditional skin-based allergy tests. We have also identified a promising biomarker, eosinophil peroxidase (EPX), that can be measured in the serum and tracks with treatment response as measured on esophageal biopsies. The proposed study has been designed to be highly responsive to PAS 20-160, a new “small R01” mechanism that encourages pilot/feasibility clinical trials that lay the foundation for larger trials. To generate key data to estimate effect sizes, we will conduct a pilot randomized clinical trial of the allergen-specific immune signature-directed diet elimination vs sham diet elimination with the following specific aims: 1) To estimate the effect of allergen-specific immune signature- directed dietary elimination compared to sham elimination on esophageal eosinophil counts and symptoms of dysphagia in patients with EoE; and 2) To assess serum EPX as a non-invasive biomarker and estimate effect sizes for monitoring dietary elimination treatment response in patients with EoE. This innovative pilot/feasibly trial will be conducted by an existing multidisciplinary team with recognized expertise in EoE, clinical trials, food allergy, pathology, and translational science. It will ultimately lead to a major clinical impact on the treatment and monitoring of EoE by individualizing dietary elimination and streamlining monitoring of dietary elimination using non-invasive biomarkers, so patients can avoid the time, effort, and risk of empiric dietary elimination.