Refractory eosinophilic esophagitis: what to do when the patient has not responded to proton pump inhibitors, steroids and diet

Abstract

Purpose of reviewManagement for patients with refractory eosinophilic esophagitis (EoE) remains a clinical challenge. This review aims to define refractory EoE, explore rates and reasons for nonresponse, and discuss the evidence that informs the approach to these patients.Recent findingsMany patients will fail first-line therapies for EoE. Longer duration of therapy can increase response rates, and initial nonresponders may respond to alternative first-line therapies. There are ongoing clinical trials evaluating novel therapeutics that hold promise for the future of EoE management. Increasingly, there is recognition of the contribution of oesophageal hypervigilance, symptom-specific anxiety, abnormal motility and oesophageal remodelling to ongoing clinical symptoms in patients with EoE.SummaryFor refractory EoE, clinicians should first assess for adherence to treatment, adequate dosing and correct administration. Extending initial trials of therapy or switching to an alternative first-line therapy can increase rates of remission. Patients who are refractory to first-line therapy can consider elemental diets, combination therapy or clinical trials of new therapeutic agents. Patients with histologic remission but ongoing symptoms should be evaluated for fibrostenotic disease with EGD, barium esophagram or the functional luminal imaging probe (FLIP) and should be assessed for the possibility of oesophageal hypervigilance.

Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence?

“…Multiple guidelines are available to offer exhaustive and evidence-based treatment recommendations. We propose a treatment algorithm based on these guidelines, systematic reviews and expert consensus (figure 2) (1, 4,36,68,[83][84][85][86][87][88].…”

Anti-IL-5 Pathway Agents in Eosinophilic-Associated Disorders Across the Lifespan

“…Eosinophilic esophagitis is an antigen-driven non-IgE-mediated disease, sustained by a type 2 inflammation, and defined by the presence of at least 15 eosinophils per high power field (HPF) on esophageal biopsies [ 91 ]. This condition is responsible for different clinical patterns, with a prevalence of dysphagia, food impaction, and chest pain in adults, and non-specific symptoms commonly present in children, such as vomiting, feeding difficulties, and failure to thrive [ 92 ]. Older patients (aged >65 years) are rarely affected, accounting for less than 10% of the adult population with EoE [ 93 , 94 ], and performing no significant differences in clinical presentations, except for a lower recurrence of food allergy, asthma [ 93 ], and atopic dermatitis [ 94 ].…”

Remission in Type 2 Inflammatory Diseases: Current Evidence, Unmet Needs, and Suggestions for Defining Remission in Chronic Rhinosinusitis with Nasal Polyps

“…In patients with EoE, there is a low correlation between symptoms and endoscopic or histological features [ 25 ]; therefore, a combination of both features is required to obtain a clinically meaningful definition of disease activity [ 26 ]. In terms of the measures used, the EoEHSS has been recommended for histological assessment based on its validity, while the EEsAI is recommended for symptomatic assessment in adults based on its validity and responsiveness [ 27 , 28 ].…”