Israel Medical Association Journal

Background: Proton pump inhibitors (PPIs) are a common and effective management strategy for eosinophilic esophagitis (EoE) leading to successful remission in most cases. However, there is uncertainty regarding the ideal follow-up pharmacological treatment to maintain remission. We performed a cost-effectiveness and quality-adjusted life year (QALY) analysis.

Objectives: To compare various approaches of pharmacologic treatments for EoE.

Methods: A Markov model was constructed to evaluate the cost-effectiveness and QALY of maintenance therapies for eosinophilic esophagitis, including PPI, topical corticosteroids (tCS), and no treatment strategy, with crossover in treatments for primary and secondary nonresponse. The primary outcomes were incremental cost-effectiveness and QALY at a 5-year time horizon.

Results: In the base-case scenario (5-year time horizon), the average costs were no treatment:₪ 73,075, PPI:₪ 81,455, and tCS:₪ 145,669 as maintenance therapy, with PPI being the dominant strategy (more effective/less costly), and a QALY of 45543, 4.5538, and 4.2283, respectively.

Conclusion: PPI was the most effective/least costly maintenance therapy. PPI is also the most cost-effective pharmacologic strategy. The relatively low adverse effects of this treatment, in addition to its effectiveness and low cost, make it an ideal choice following successful PPI induction treatment.

Background: Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the "Graz model."

Objectives: To investigate the Graz model for tube weaning and for treating severe selective eating disorders in one center in Israel. 

Methods: Pre-program assessment of patients’ suitability to participate was performed 3 months prior to the study, and a treatment goal was set for each patient. The program included a multidisciplinary outpatient or inpatient 3 week treatment course. The major outcome measures were achievement of the target goal of complete or partial tube weaning for those with tube dependency, and expansion of the child's nutritional diversity for those with selective eating. 

Results: Thirty-four children, 28 with tube dependency and 6 with selective eating, participated in four programs conducted over 24 months. Their mean age was 4.3 ± 0.37 years. Of all patients, 29 (85%) achieved the target goal (24 who were tube-dependent and 5 selective eaters). One patient was excluded due to aspiration pneumonia. After 6 months follow-up, 24 of 26 available patients (92%) maintained their target or improved. 

Conclusions: This intensive 3 week program was highly effective in weaning children with gastrostomy tube dependency and ameliorating severe selective eating. Preliminary evaluation of the family is necessary for completion of the program and achieving the child’s personal goal, as are an experienced multidisciplinary team and the appropriate hospital setup, i.e., inpatient or outpatient.