Small Study Indicates Adults With EoE Can Tolerate Sterilized Milk

Sterilized milk did not trigger eosinophilic esophagitis (EoE) in most patients with a documented history of EoE triggered by milk proteins, according to a recent study.

Cow's milk is the most common food trigger for EoE, a chronic inflammatory disease caused by type 2 inflammation; it is marked by the accumulation of immune cells, such as eosinophils, basophils, and mast cells in the esophagus. Symptoms of EoE vary by age and include dysphagia, impaction, regurgitation, chest and/or abdominal pain, and vomiting.

Patients with EoE typically restrict 2, 4, or 6 foods from their diet, which affects their nutrition, health-related quality of life (HRQOL), as well as impacting their work, school, and other activities.

This food restriction is similar to those with food allergies that are mediated by immunoglobulin E (IgE), although IgE-mediated food allergies may lead to severe allergic reactions and in rare cases, death. In recent years, research has shown that baked milk can be tolerated by many with IgE-mediated food allergy, and some research has also shown this method works for some EoE cases as well.

But whether patients with EoE can tolerate sterilized liquid milk is unknown.

In this study, conducted in Spain between 2018-2021, researchers recruited 20 patients, 18 of whom were included in the study. Most (13) were male and were in remission from EoE.

The aim was to evaluate tolerance of sterilized cow's milk—that is, boiled for 20 minutes instead of milk subjected to ultra-high temperature processing (UHT)—to see if remission could be maintained. The study also examined HRQOL effects, nutritional intake, and allergic sensitization as measured by blood and skin tests.

Baseline assessments included eosinophil counts, and patients were included if endoscopy and biopsies were normal, with a peak eosinophil count below 15 cells per high-power field. The participants were nonresponders to proton pump inhibitors, a first-line therapy for EoE. Certain asthma and rhinitis medicines were allowed for exacerbations, but whenever possible, other therapies for allergies and asthma were withdrawn.

The mean age was 32 (13.4) years (range, 13–59 years) and the average disease duration from diagnosis was 8 (7) years (range, 2–12). Nearly a third had food allergy, almost 17% had atopic dermatitis, and about 67% had both asthma and allergic rhinitis.

Participants were given 200 ml of sterilized cow's milk twice daily for 8 weeks.

Endoscopic assessment, peak eosinophil counts, esophageal-related symptoms, HRQOL, blood eosinophils, eosinophil cationic protein, skin prick test and serum total and specific IgE to major milk proteins were monitored before and after.

Twelve of the 18 maintained remission, while EoE recurred in 6 participants.

For the 6 who were unable to tolerate the sterilized milk, their dysphagia worsened and their eosinophilia count went up. They also had worse HRQOL, particularly when it came to diet and social/emotional factors. Cow's milk-specific IgE also increased slightly in these patients.

One-year follow-up data were available for 10 patients who successfully tolerated sterilized milk and maintained remission; they also consumed products with baked milk.

All were asymptomatic. In addition, 4 of the 10 were still successfully having sterilized milk and baked milk products for a total of 2 years, with no return of symptoms.

Although the study was small, the authors said they believe it is “the largest and most rigorous systematic evaluation of tolerance to sterilised cow's milk in patients with EoE triggered and maintained by milk and represents a potential opportunity for EoE patients to have HRQoL and adhere to a diet, without putting their health at risk.”

The authors noted several limitations with the study, including its small sample size, that it was carried out at a single center, and symptoms were not assessed using a validated instrument. They also cautioned that the study results cannot be generalized to children, and that additional research is needed.

Reference

González-Cervera J, Arias A, Navarro P, et al. Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk. Aliment Pharmacol Ther. Published online August 2, 2022. doi:10.1111/apt.17171