Of available treatments, topical steroids are most effective at inducing clinical and histologic remission in patients with eosinophilic esophagitis (EoE, in about two-thirds of patients), but proton pump inhibitors (PPIs) are the most frequently prescribed, followed by dietary therapies, found an analysis of data from a large cohort of patients in Europe. The findings provide evidence on the effectiveness of drug- and diet-based anti-inflammatory therapies for EoE in real-world practice.
Emilio J. Laserna-Mendieta et al analyzed data from EoE CONNECT, a multicenter database that provides high-quality information on the management of EoE in Europe. The authors collected data on the efficacy of different therapies for EoE from 589 patients, treated at 10 centers in Spain and 1 in Italy.
The first-line treatments were PPIs for 450 patients (76.4%), topical steroids (mostly off-label swallowed fluticasone) for 62 patients (10.5%), and dietary therapies for 46 patients (7.8%). Only 1.7% of patients received endoscopic dilation as the first-line treatment.
When the effectiveness in inducing clinical and histologic disease remission or response was assessed together, topical steroids were the most effective first-line therapy, inducing remission or responses in two-thirds of patients.
Among patients given topical steroids as a first-line therapy, 55.8% achieved complete clinical remission and 27.9% had symptom responses (based on the Dysphagia Symptoms Score, DSS). Empiric elimination diets (EEDs) induced remission of symptoms in 52.0% of patients and a response in 28.0% of patients. PPIs induced clinical remission in 47.8% of patients and a response in 24.0%.
Swallowed topical steroids were the most effective first-line option for induction of histologic response or remission, reducing peak eosinophil counts below the threshold of 15 eos/hpf in 67.7% of patients overall. PPIs used as initial therapy achieved histologic response or remission in 49.7% of patients, and EEDs in 48.1% of patients.
Laserna-Mendieta et al state that because of the low number of cases with a measured clinical response in the topical steroid and EED groups (43 and 25 patients, respectively), these results should be considered with caution. A symptom response occurred in all but 1 of the 14 patients who underwent endoscopic dilation (alone or combined with anti-inflammatory therapies).
Dietary interventions and topical steroids (fluticasone propionate for almost all patients) were more commonly chosen for children, whereas PPIs were preferred for adults. In a multinomial logistic regression model, only referral center and the presence of endoscopic features of fibrosis remained independently associated with the choice of a first-line therapy.
For second-line therapies, topical steroids (fluticasone propionate for 73.8% and budesonide for 26.2%) induced histologic response or remission (defined as peak eosinophil counts <15 eos/hpf) in 78.8% of patients, although only 33 patients were fully assessed. PPIs as second-line therapies induced response or remission in 64.8% of patients.
Limitations of the study included assessment of symptoms with the nonvalidated DSS, which is of limited utility to document changes in symptoms of EoE in the short term. In addition, only about 15% of patients were younger than 18 years old, limiting the validity of the results for pediatric populations. Most recruiters were gastroenterologists attending adult patients, so potential differences in patient management compared with allergists and pediatricians were not explored.
However, the findings provide evidence for the effectiveness of drug and diet-based anti-inflammatory therapies for EoE in real-world practice and confirms their role as first- and second-line therapies. Site-related preferences, stricturing phenotype, and features of fibrous remodeling in baseline endoscopy accounted for variations in effects in clinical practice.
The figure shows models for pathogenesis of EoE from the review article ‘Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis’ by Ikuo Hirano and Glenn T. Furuta, published in Clinical Gastroenterology and Hepatology, volume 158, issue 4, pp 840-851, MARCH 01, 2020.