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

What is the Role for Combining or Transitioning to Other First-line Therapies?

There are limited data on the efficacy of transitioning patients to a different first-line therapy. For patients who fail treatment with a topical corticosteroid, a trial of an alternative formulation should be considered, as fluticasone 880 μg twice daily (b.i.d.) and budesonide 1 mg (b.i.d.) have comparable efficacy of 71 and 64% (P = 0.38) as shown in the landmark randomized clinical trial by Dellon et al..[20] In one study, PPI therapy was less effective in inducing clinical and histologic remission for patients who had previously failed diet or swallowed corticosteroids than when used as a primary therapy.[31] A European observational study evaluated 344 patients who failed a first-line therapy and were subsequently switched to another therapy. Of these patients, 78.8% of patients who transitioned to topical steroids achieved histologic remission (eos <15/hpf) compared with 64.8% of patients switched to PPIs, and 39.4% of patients switched to diet.[33]

Although commonly done in clinical practice, evidence supporting combination therapy is limited. In theory, a combination of PPIs, diet and topical corticosteroids targets different aspects of the underlying pathophysiology of EoE. An observational study of 23 patients, who did not respond to SFED or topical steroid monotherapy, examined the response of these patients to combination therapy with heterogeneous dietary treatments and a swallowed corticosteroid. At a mean of 4 months, 88% of patients reported global symptomatic improvement with an associated decrease in eosinophil count (54 to 36 eos/hpf). At 30.5 months, 82% of patients had a global symptomatic response, despite having a mean peak eosinophil count similar to baseline (54 versus 46, P = 0.34).[34] Another observational study of 71 adult and paediatric patients did not show a difference in outcomes for combination therapy of topical corticosteroids and a PPI compared with steroid monotherapy.[35] As such, data to date support transitioning to an alternative first-line therapy with the highest success rates being for topical steroids. The data evaluating combination therapies are limited, but combining a PPI and steroids or diet could be considered in clinical practice if switching to an alternative first-line therapy is not successful.