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Recent Advances in EoE Treatment
Recent Advances in the Treatment of Eosinophilic Esophagitis

Released: September 20, 2024

Expiration: September 19, 2025

Jonathan M. Spergel
Jonathan M. Spergel, MD, PhD
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Key Takeaways
  • Eosinophilic esophagitis (EoE) is a chronic disease that must be treated; if a patient is taking a therapy with good results and decides to stop it, their symptoms and consequences associated with EoE will return.
  • Dupilumab and oral budesonide have been FDA-approved for the treatment of EoE.

In the last couple of years, 2 therapies were approved for the treatment of eosinophilic esophagitis (EoE): dupilumab, which has been approved for patients as young as 1 year old, and oral budesonide (budesonide oral suspension). In addition to these exciting advancements, several other therapies are being studied in phase III clinical trials for use in EoE. 

Dupilumab and oral budesonide have demonstrated good efficacy and tolerability in the treatment of EoE. Clinical trials for both agents have reported on 2 primary endpoints: symptom and histologic response. Patient response is typically a measure of dysphagia or food impactions. Although we want to see a reduction in those symptoms, dysphagia is not always present in EoE, so other symptoms such as abdominal pain or vomiting must be assessed. Response is also determined via histology. A normal esophagus has 0 eosinophils per high-power field, and we want to see less than 6, aiming for as close to 0 as possible.

An endoscopy with biopsy is performed at baseline and again at the end of treatment. After about 6 months, the histologic response rate to dupilumab was 68%, and when it was extended to 12 months, the response rate showed a slight improvement (~79%), but there was no placebo control. The response rate to budesonide was relatively similar (77%). However, budesonide was approved only for use as a short-term therapy, and the dose is approximately 2 to 4 times higher than the standard dose used for EoE. This leaves us with a clinical gray area as the treatment of EoE requires ongoing therapy.

Individualizing EoE Care With New Agents
One looming question is whether we need to strictly use the approved doses of available agents, which may vary from the doses we have historically used or those that are used with these agents for other conditions. The patients who are enrolled in clinical trials tend to be our most severe cases. Patients with less severe disease may need a smaller dose or may be able to be weaned from their medication entirely. In 2022 we published a study on the dose of dupilumab used to treat asthma and atopic dermatitis, which is half the dose for EoE, and most patients responded. One reasonable strategy is to start with the approved doses and reduce the dose if a clinical response is observed via endoscopy and symptom monitoring, even if the medication cannot be stopped altogether.

Some patients who were already taking swallowed corticosteroids (eg, a mixture of budesonide nebulized solution with sucralose to ingest orally or swallowed aerosolized fluticasone) wanted to switch to the newly FDA-approved oral budesonide suspension because they do not like to mix the medication themselves or find the premixed medication to be simpler, so we give them the option to choose. In the absence of direct pharmacologic comparison, we assume the dosing between the products is similar, so if they were mixing 1 mg for each budesonide dose before, we try to keep them on 1 mg once daily of the premixed preparation. 

The dosing of oral budesonide can be tricky. The approved dose is 2 mg, but many of our patients take 1 mg once or twice daily. In these cases, we recommend switching over to 2 mg twice daily. If the patient does well on this dose and their symptoms improve and endoscopy is unremarkable, we then try to cut their dose by half. 

Employing Shared Decision-making in EoE Care
We also use shared decision-making when designing therapy plans with patients. We typically start out with a discussion about diet. The vast majority of patients with EoE have a food allergy, so in these cases, we simply remove the trigger food. Clinical trial results suggest that removing milk and wheat likely works in approximately 40% of patients, and removing milk from the diet may be simple for most patients; we do not need to prescribe the very restrictive diets that we did 20 years ago. 

The first route we always take with pharmacotherapy in our patients with EoE is a proton pump inhibitor (PPI), which is the standard of care. Some patients improve with this medication, and if they do, we stop looking for alternatives. If the PPI fails to improve the outcomes as desired, we give them other options. However, it is sometimes difficult to assess if a PPI has been successful in meeting our desired treatment goals, especially in pediatric patients. 

Beyond PPIs, we then consider other pharmacotherapy options, such as oral budesonide or dupilumab. We discuss the differences with the patient, including the frequency and route of administration, the anticipated effectiveness of each option related to symptom management and biopsy improvements, and considerations for side effects. From there, we collaborate with the patient to choose the best therapy for them.

It is imperative to convey to patients and HCPs that EoE is a chronic disease, so if medication is ceased, the symptoms will return and there is a risk of disease complications. We inform the patient that they can change their mind about treatment, but some action must be taken. All patients with EoE need therapy, but what is right for one may be different for another. 

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