First-line treatments for EoE consist of PPIs, swallowed corticosteroids, diet and oesophageal dilation (see Figure 1 for management algorithm). However, many patients will not have histologic remission after an initial course of therapy, and with rare exceptions, we are unable to predict who will respond to what therapy. When faced with a patient with refractory EoE, clinicians should assess for an alternative cause of oesophageal eosinophilia, compliance, appropriate route of medication administration and adequate dosage prior to changing therapy. Optimization of current treatment can be considered with extension to 12 weeks. Switching to an alternative first-line therapy can be successful with highest response rates for steroids. Combination therapy is often used in practice, but additional studies are needed to define response rates. An elemental diet or systemic steroids can be considered in patients with refractory EoE with severe symptoms. Patients with histologic remission but ongoing symptoms should have evaluation for fibrostenotic disease with EGD, barium swallow or FLIP and for symptom-specific anxiety and oesophageal hypervigilance. Patients who do not respond to any first-line treatment should consider enrolling in clinical trials on novel therapeutics. At this time, there remain many unanswered questions for managing the patient with refractory disease (Table 4).
This is a suggested treatment algorithm for managing patients with refractory eosinophilic esophagitis. After a trial of a first-line therapy, patients with histologic remission but ongoing symptoms should have evaluation for fibrostenotic disease with EGD, barium swallow or FLIP and for symptom-specific anxiety and oesophageal hypervigilance. After assessing for adherence and correct administration, patients who do not respond to first-line treatments should consider changing duration or dosing of initial therapy or trying alternative first line therapy. With continued nonresponse, one can consider combination therapy, enrolling in clinical trials of novel therapeutics or elemental diets.
Financial support and sponsorship
This work was supported in part by the NIH/NIDDK Center for Molecular Studies in Digestive and Liver Disease P30DK050306 and by the Consortium for Eosinophilic Gastrointestinal Disease Research (CEGIR) U54 AI117804, which is part of the Rare Disease Clinical Research Network (RDCRN), an initiative of the Office of Rare Diseases Research (ORDR), NCATS and is funded through collaboration between NIAID, NIDDK and NCATS. CEGIR is also supported by patient advocacy groups, including American Partnership for Eosinophilic Disorders (APFED), Campaign Urging Research for Eosinophilic Diseases (CURED) and Eosinophilic Family Coalition (EFC). As a member of the RDCRN, CEGIR is also supported by its Data Management and Coordinating Center (DMCC) (U2CTR002818).
Curr Opin Gastroenterol. 2022;38(4):395-401. © 2022 Lippincott Williams & Wilkins