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Allergist’s Take on Managing EoE
An Allergist’s Perspective: Evidence-Based Updates on Early Recognition and Management of EoE

Released: April 04, 2023

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Key Takeaways
  • EoE is a common, chronic, and progressive inflammatory condition that can significantly affect patients’ quality of life and health outcomes if not readily recognized and treated.
  • Traditional strategies used to manage EoE are not approved by the FDA and have unique challenges related to cost, adherence, and ease of use.
  • Dupilumab is the first FDA-approved biologic agent for EoE management and has demonstrated improvement in dysphagia symptoms and histologic remission.

This commentary summarizes key takeaways from a recent Clinical Care Options satellite symposium at the 2023 American Academy of Allergy, Asthma & Immunology Annual Meeting titled, “Optimizing the Management of EoE: Key Insights from the Allergist’s Perspective.” Watch the on-demand webcast here and download the slides here. 

Important Considerations About the Diagnosis of Eosinophilic Esophagitis (EoE) 
EoE is a chronic inflammatory condition that is increasing in prevalence and is currently underrecognized. The condition can occur at any age and is 3 times more likely to present in male vs female patients. Nearly one quarter of patients receiving an endoscopy because of symptoms of dysphagia will have evidence of EoE, and despite being characterized as a disease only recently, it is now known to be the leading cause of bolus food impaction. 

Symptoms may vary based on patient age, with children experiencing symptoms consistent with reflux, feeding difficulties, poor weight gain, and, at times, oral aversion. This can progress to abdominal and chest pain. Adolescents and adults primarily experience dysphagia, with or without food impaction. When clinical symptoms of EoE are present, healthcare professionals should refer patients to an allergist or gastroenterology specialist for a full evaluation. 

Timely evaluation, diagnosis, and treatment are key, as delays or missed diagnoses can result in histologic changes in the esophagus that progressively worsen, leading to the development of fibrostenotic disease. Often, especially in pediatric patients, the esophagus may appear normal at first, resulting in the potential for a missed diagnosis, particularly if insufficient biopsies are collected upon endoscopy. Current guidance recommends collecting ≥6 biopsies from ≥2 different esophageal levels. It is important to obtain biopsies from the distal level and then additional biopsies from the mid or proximal levels. In the presence of EoE, biopsies can reveal characteristic signs of the condition (patchy irregularities, basal zone hyperplasia, dilated intercellular spaces, fibrosis, and smooth muscle hypertrophy) and ≥15 eosinophils per high-power field. In addition, it is important to rule out other causes of esophageal eosinophilia (eg, gastroesophageal reflux disease, Crohn’s disease, infective processes). 

Benefits and Challenges of Traditional Treatment Strategies for EoE
Treatment of EoE can involve dietary modifications, pharmacologic therapies, and/or esophageal dilation procedures. There are several approaches to employing elimination diets, which can be effective with close adherence and can limit the need for a chronic medication and potential related adverse events. However, most forms of prescribed diets are difficult to maintain long term, can be costly and require additional access to specialized care, and may require multiple endoscopies to confirm each patient’s triggering food. 

Corticosteroids applied topically and proton pump inhibitors (PPIs) currently are used to treat EoE. Although they are recommended by the American Gastroenterological Association and the Joint Task Force on Practice Parameters, none of these agents is approved by the FDA for treatment of EoE. Strategies commonly used in the United States include liquid budesonide pulmonary nebulizer solution mixed with sucralose packets or fluticasone sprayed from a metered dose inhaler into the mouth, then swallowed. This is used twice daily, with the last dose at bedtime to increase esophageal exposure. Because oral candidiasis is a risk of this strategy, patients should be educated on how to monitor for it and what to do if it occurs. Both topical corticosteroids and PPIs demonstrated histologic and symptom improvement in EoE trials and have the benefits of easy administration, relatively low cost, and a reasonable safety profile. When used, PPIs should be started at the higher dosing range twice daily. 

New and Emerging Therapies for EoE
Dupilumab is the first and only agent currently approved to treat patients 12 years of age or older with EoE. A study to evaluate its use in those 1-11 years of age is ongoing. This monoclonal antibody blocks interleukin (IL)‒4 and IL-13 signaling by binding to the IL-4 receptor α subunit, thereby decreasing type 2 inflammation. In a placebo-controlled phase III trial, Dellon and colleagues evaluated dupilumab dosed at 300 mg SC in participants with histologically confirmed EoE. Patients receiving PPI therapy ahead of randomization continued baseline therapy, but new initiation of a PPI was prohibited. Similarly, those who had been stable on an elimination diet ahead of the trial were allowed to continue through the treatment period. Patients receiving topical corticosteroids within 8 weeks of the treatment period were excluded from participation.

Weekly dupilumab decreased symptoms of dysphagia, and patients achieved histologic remission (defined as <6 eosinophils per high-power field) at 24 and 52 weeks. The safety profile was similar to that observed when using dupilumab for other indications (eg, atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis). The most frequent adverse event was injection-site reactions. 

Other biologic agents currently being evaluated in phase II or III trials for their potential to treat EoE include those targeting IL-5, Siglec-8, IL-13, thymic stromal lymphopoietin, and the sphingosine-1-phosphate receptor. During this exciting time with a robust pipeline for EoE care, healthcare professionals should be aware of EoE diagnostic criteria and therapeutic options for timely recognition and effective management to improve patient- and disease-related outcomes. 

Intentional and Coordinated Transitions of Care for Patients With EoE  
Because EoE is a chronic condition, often appearing in childhood and continuing across the lifespan, it is important to consider a strategy for transitioning from the pediatric to adult care setting. This can be a very vulnerable time for patients. Optimal transitioning requires readiness assessments, education delivery, and several care coordination steps. Developing a transition plan or policy at each practice is recommended to cover these steps with flexibility to individualize the plan for each patient. Implementation starts with initial discussions with the patient and caregiver early—between 12 and 14 years of age, if appropriate. Over time, the patient should be encouraged to take more ownership of their care while they still have the necessary support of the pediatric care team and their caregivers. When the patient is ready to transition to an adult care team, consider having a joint review of medical records, an avenue to debrief about the disease course, and/or a joint patient visit with the pediatric and adult teams. Incorporating these steps into routine care can facilitate self-efficacy of EoE management and is key to optimizing patient- and disease-related outcomes. 

Your Thoughts?
What are your thoughts and questions on best practices in the timely recognition and management of EoE? Please answer the polling question and join the conversation by posting a comment in the discussion section below.

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When would you consider incorporating novel systemic therapies such as dupilumab into the therapeutic plan for EoE in your practice?  

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