Baked Milk and Small Quantity Straight Milk Is Tolerable in Milk-Triggered Eosinophilic Esophagitis

Introduction: Cow's milk is the most common food trigger in eosinophilic esophagitis (EoE). A milk elimination diet can be an effective treatment in EoE, however long-term compliance remains a concern. While some patients with IgE-mediated milk allergy tolerate baked milk, the effects of baked milk or small quantities of straight milk in EoE patients successfully treated with milk elimination diet is unknown. Methods: This was a prospective pilot trial of 6 EoE patients with confirmed histologic response to a milk elimination diet. Patients underwent dietitian directed baked milk introduction in the form of a standardized muffin (5 servings per week) for 6 weeks. Histologic disease activity was assessed via the esophageal cytosponge as previously described. Symptoms were assessed by the validated EoE symptom activity index (EEsAI) and the esophageal hypervigilance and anxiety scale (EHAS-7) pre- and post-baked milk introduction. 4 of these patients then underwent straight milk introduction, starting with 1 glass (8 oz) of milk per week for 4 weeks, followed by 3 glasses of milk per week for 4 weeks, with symptomatic and histologic assessment after completing each amount as described above. Histologic remission was defined as < 15 eos per HPF and deep remission ≤ 6 eos per HPF on sponge cytology. Symptomatic remission was defined as EEsAI PRO score < 20. Results: All 6 patients remained in deep histologic remission after 6 weeks of the baked milk muffin and the absolute change in peak eosinophil count was 0 (interquartile range 0-1). (Table 1 and Figure 1) All 4 patients who completed 3 glasses of milk per week remained in deep remission with an absolute increase in peak eosinophil count of 2 (interquartile range 0-3). There was no increase in EEsAI score from baseline with baked or straight milk. EoE-QOL-A scores increased with baked milk and straight milk (Figure 1). There was no change in hypervigilance (EHAS-7) after the baked milk. Conclusion: This is the first prospective study to evaluate tolerance of baked and straight milk in patients with milk-triggered EoE. All patients remained in deep histologic and symptomatic remission after regular baked milk and small volume straight milk intake with numerical improvement in quality of life and no deleterious effect on symptoms at 4-6 weeks time. These findings suggest that patients with milk-triggered EoE may be able to tolerate baked milk and small amounts of dairy in their diet which may improve the long-term durability of this treatment approach.Figure 1.: Trends in EoE-QOL-A score and eosinophil count on sponge cytology after baked milk and straight milk introduction. Table 1. - Baseline and median change in eosinophil count and patient questionnaire scores after introduction of baked and straight milk Baseline (Q1, Q3) Change after 6 weeks baked milk (Q1, Q3) P value* Change after 1 glass milk per week (Q1, Q3) P value* Change after 3 glasses milk per week (Q1, Q3) P value* Eosinophils 0.0 (0.0, 0.0) 0.0 (0.0, 1.0) 0.5000 0.5 (0.0, 3.5) 0.500 2.0 (0.0, 3.0) 0.500 EEsAI Score 6.0 (0.0, 12.0) 0.0 (0.0, 0.0) 1.0 0.0 (-6.0, 0.0) 1.0 0.0 (0.0, 0.0) 1.0 EoE-QOL-A Score 99.0 (90.0, 100.0) 3.0 (-3.0, 6.0) 0.4688 5.0 (-7.0, 10.5) 0.8750 6.0 (4.0, 13.0) 0.1250 EHAS-7 Score 10.5 (8.0, 13.0) 0.0 (-2.0, 1.0) 0.7500 *Changes from baseline were assessed for significance, with P values calculated using the Wilcoxon signed rank test (a non-parametric test).