Refractory Eosinophilic Esophagitis: What to do When the Patient has not Responded to Proton Pump Inhibitors, Steroids and Diet

Alexandra L. Strauss; Gary W. Falk


Curr Opin Gastroenterol. 2022;38(4):395-401. 

In This Article

Can we Optimize Current Treatments?

There is some evidence that changes in dosage and duration of available therapies can impact response rates. In current practice, most providers perform trials of therapy with evaluation for treatment response in approximately 8 weeks. However, emerging data suggest that duration of therapy may favourably impact remission rates. In a 5-year observational study on the Swiss EoE cohort, longer treatment course of budesonide was associated with a higher rate of complete (endoscopic, clinical, histologic) remission.[21] In a randomized clinical trial in Europe, budesonide orodispersible tablets resulted in clinical and histologic remission in 58% of individuals at 6 weeks, which increased to 85% at 12 weeks.[28,29] There was, however, no difference between the budesonide 1 mg twice-daily versus 2 mg twice-daily doses.[29] A randomized clinical trial found that 26% of patients who did not initially respond to fluticasone propionate orally disintegrating tablets at 12 weeks then achieved histologic remission when treatment was extended to 52 weeks.[30] A large observational study found that 50.4% of patients achieved clinico-histologic remission (eos <15/hpf) after 8–10 weeks on a PPI, which increased to 65.2% with 10–12 weeks of therapy. The histologic remission rate was higher for patients treated with high-dose PPI therapy than standard or low-dose therapy (50.8 versus 35.8%, P = 0.027) with no difference between different PPI formulations.[31] For dietary therapy, one study found seven patients with a partial reduction in eosinophils (average 38.5 to 21.5 at 6–8 weeks) in response to an elimination diet. These patients then underwent an extended period of dietary elimination (mean of 13 additional weeks), which led to histologic remission (<15 eos per hpf) in all patients.[32] Other work has found no improvement in clinical and histologic response when treatment duration was increased beyond 10 weeks for dietary therapy, 12 weeks for PPIs or 16 weeks for topical steroids.[33] Overall, the evidence suggests that an increased duration of therapy beyond 8 weeks may be beneficial for a subset of patients who do not achieve histologic remission. For patients on low-dose or standard-dose PPI therapy, an increase to high-dose PPI should be considered.