Medical treatment of eosinophilic esophagitis

Abstract

Background Eosinophilic esophagitis (EoE) is a chronic antigen‐mediated eosinophilic inflammatory disease isolated to the esophagus. As a clinicopathologic disorder, a diagnosis of EoE requires a constellation of clinical symptoms of esophageal dysfunction and histologic findings (at least 15 eosinophils/high‐powered microscope field (eos/hpf)). Current guidelines no longer require the failure of response to proton pump inhibitor medications to establish a diagnosis of EoE, but continue to suggest the exclusion of other etiologies of esophageal eosinophilia. The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications. Currently, there is no cure for EoE, making long‐term treatment necessary. Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy. Effective pharmacologic therapies include corticosteroids, rapidly emerging biological therapies, and proton pump inhibitor medications. Objectives To evaluate the efficacy and safety of medical interventions for people with eosinophilic esophagitis. Search methods We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP to 3 March 2023. Selection criteria Randomized controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of eosinophilic esophagitis, either alone or in combination, to any other intervention (including placebo). Data collection and analysis Pairs of review authors independently selected studies and conducted data extraction and risk of bias assessment. We expressed outcomes as a risk ratio (RR) and as the mean or standardized mean difference (MD/SMD) with 95% confidence interval (CI). We assessed the certainty of the evidence using GRADE. Our primary outcomes were: clinical, histological, and endoscopic improvement, and withdrawals due to adverse events. Secondary outcomes were: serious and total adverse events, and quality of life. Main results We included 41 RCTs with 3253 participants. Eleven studies included pediatric patients while the rest recruited both children and adults. Four studies were in patients with inactive disease while the rest were in patients with active disease. We identified 19 intervention comparisons. In this abstract we present the results of the primary outcomes for the two main comparisons: corticosteroids versus placebo and biologics versus placebo, based on the prespecified outcomes defined of the primary studies. Fourteen studies compared corticosteroids to placebo for induction of remission and the risk of bias for these...

Swallowed topical steroid therapy for eosinophilic oesophagitis in children: practical, evidence-based guidance by the BSPGHAN Eosinophilic Oesophagitis Working Group

“…gov and WHO ICTRP on 3 March 2023, with no prior date limits, using Cochrane guidance. 8 Search criteria were randomised controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of EoE. Dichotomous analysis was undertaken to assess response, either alone or in combination to any other intervention (including placebo).…”

“…8 9 There is emerging evidence showing that combination therapy of STS with PPI may lead to even better outcomes. 8 Currently, there are no data in pEoE showing that the use of STS will prevent oesophageal strictures or that strictures can be treated in isolation with STS. However, in practice, medical treatment is often trialled before therapeutic balloon dilatation.…”

“…Figure1Key evidence from the Cochrane review. The Cochrane review provides analysis of 52 statements on the use of swallowed topical steroid (STS) for the endpoints; successful reduction of eosinophils, resolution of symptoms (dichotomous), mean drop in eosinophils and mean reduction in symptom score (continuous) 8. The key findings are from 41 randomised controlled trials (RCTs) with 3253 participants, of which 14 studies compared corticosteroids to placebo for induction of remission in children alone or children and adults.…”

Mechanistic Insights into Eosinophilic Esophagitis: Therapies Targeting Pathophysiological Mechanisms

“…Standard treatment therapies include dietary modification [11,13], esophageal dilation, and pharmacologic therapy [13,14]. Effective pharmacologic therapies include corticosteroids, rapidly evolving biological therapies, and proton-pump inhibitors (PPIs) [15]. A variety of novel therapeutic strategies have been developed targeting different cellular and soluble mediators that contribute to the complex mechanisms of the disease [16].…”

Assessment of the Severity and the Remission Criteria in Eosinophilic Esophagitis

“…The management of EoE is based on diet and drug therapy that includes proton pump inhibitors (PPIs), topical steroids, and biological therapy (with antibodies to IL-4, IL-5, IL-13, etc.) [17][18][19][20][21]. Esophageal strictures can be successfully treated with dilation.…”