Current treatment options and long-term outcomes in patients with eosinophilic esophagitis

ABSTRACT

Introduction

Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited.

Areas covered

Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term.

Expert opinion

Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.

KEYWORDS:

• Budesonide
• diet therapy
• dilation
• eosinophilic esophagitis
• fluticasone
• food elimination diet
• food hypersensitivity
• formulated food
• long-term care
• proton-pump inhibitor
• swallowed corticosteroids

Article highlights

• EoE is chronic condition in which symptomatic, endoscopic, and histological disease activity recurs when successful treatments are stopped.

• Mounting evidence suggests that left untreated, persistent eosinophilic esophageal inflammation progresses to fibrous remodeling over time, giving rise to structures and narrow-caliber esophagus. Therefore, maintenance therapy in EoE is strongly recommended.

• Knowledge about EoE phenotypes is limited. A relevant proportion of patients show a mild non-progressive clinical and endoscopic pattern. Elucidating who will and who will not benefit best from maintenance therapy remains one of the most relevant unresolved issues.

• Currently available therapies that have been proven to achieve remission in EoE include diet, PPIs and swallowed topical corticosteroids. All of these therapies have also demonstrated effectiveness in maintaining disease remission in the long term.

• Unlike induction therapy, data on the effectiveness of the different maintenance therapies is scarce, generally coming from observational studies and with a certain risk of bias.

• The same treatments used to induce EoE remission have been shown to be effective in maintaining it in the long-term. As they have generally been used at lower doses, probably suboptimal, the efficacy has been shown to be less than that for induction.

• Key unanswered questions include how to define sustained remission, the best strategies to maintain it and ensure treatment adherence, and optimal surveillance methods for its monitoring.

Acknowledgments

The authors are indebted to Melanie Radcliff for proofreading the English text.

Declaration of interest

A Lucendo has served as a speaker, and/or has received research and/or education funding and/or consulting fees from Adare/Ellodi, Dr. Falk Pharma, Regeneron, and EsoCap. J Molina-Infante has received research and/or education funding from Dr. Falk Pharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One peer reviewer is a consultant for Pulm One, Spoon Guru, ClostraBio, Serpin Pharm, Allakos, Celldex, Nextstone One, Bristol Myers Squibb, Astra Zeneca, Ellodi Pharma, GlaxoSmith Kline, Regeneron/Sanofi, Revolo Biotherapeutics, and Guidepoint; has an equity interest in the first seven listed, and royalties from reslizumab (Teva Pharmaceuticals), PEESSv2 (Mapi Research Trust) and UpToDate; and is an inventor of patents owned by their institution. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.