Treatment Guidelines

The following is a summary of currently accepted therapies in eosinophilic esophagitis, which as noted above has been the best studied of these diseases. These treatments have been reviewed in the process of developing consensus statements on the diagnosis and management of eosinophilic esophagitis (EoE). In the case of eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC), the relative rarity of these diseases has prevented the development of treatment guidelines at this time. One of the driving forces for the creation of CEGIR is to increase the number of patients studied to allow for the development of evidence-based treatment protocols.

The following is an invited article from Girish Hiremath, MD, MPH, at Vanderbilt University.

Treatment Approaches for Eosinophilic Esophagitis

Introduction

Eosinophilic esophagitis (EoE) is an allergen-mediated disease affecting all ages, worldwide.¹ Histologically, it is characterized by an eosinophil-predominant inflammation (defined as peak eosinophil count (PEC) of ≥ 15 eosinophils per high-power field) in the esophagus.² Affected individuals develop esophageal symptoms depending on their age at the onset of EoE. For instance, children commonly present with vomiting, feeding difficulties, and abdominal pain. Given its chronic and progressive course, EoE typically continues into adulthood.^3–5 A delay in diagnosis or uncontrolled eosinophilic inflammation in the esophageal epithelium can be associated with suboptimal quality of life and lead to fibrostenotic complications, such as esophageal narrowing or stricture, resulting in esophageal food impaction (EFI).^6,7 Therefore, resolution of clinical symptoms and histologic remission (defined as an improvement in eosinophilic inflammation (PEC < 15 eosinophils per high-power field and mucosal healing) are among the primary goals of treating EoE. Over the past three decades, our understanding of EoE has substantially improved. Once considered a rare and case-reportable disease,⁸ EoE has emerged as a well-characterized, clinicopathologic condition and one of the more heavily researched upper gastrointestinal diseases. Emerging evidence suggests that the type 2 helper T (Th2)–cell driven inflammation involving the T cells, eosinophils, mast cells, and the cytokines, such as interleukin (IL)-4, IL-5, thymic stromal lympopoeitin (TSLP), and IL-13, are fundamentally involved in the immunopathogenesis of EoE.^9,10 In addition, the genome-wide association studies have identified multiple genes, such as thymic stromal lymphopoietin (TSLP) and STAT6, that have a role in Th2 cell differentiation and development, as well as genes that have a vital role in epithelial cell function and esophageal epithelial barrier integrity.¹¹ More recently, the inhibitory surface receptors expressed on eosinophils, mast cells, and basophils, known as Siglecs (sialic acid-binding immunoglobulin-like lectins), have been identified. These are considered as potential therapeutic targets, especially given their specific expression on allergic inflammatory cells.¹² The growth of our knowledge base has led to the evolution of diagnostic and management guidelines from an expert opinion or consensus statement to an evidence-based approach.^13–17 It has also spurred a host of treatments and has raised the possibility of personalizing EoE therapies.

The currently accepted EoE therapies are categorized as diet, drugs, and dilation (3 D’s). The first line of treatment in a patient with uncomplicated EoE can be either a dietary or a drug-based approach. The goal of these approaches are to induce and maintain remission of EoE to minimize the risk of potential fibrostenotic complications. Choosing which approach to pursue is typically based on the shared decision-making between the patient, their caregivers (or parents in pediatric patients), and their healthcare providers.¹⁸ Endoscopic interventions, such as esophageal dilation, are generally considered for patients with complicated EoE.¹⁹

Dietary elimination

The rationale for dietary intervention is to control the eosinophilic inflammation in the esophagus by eliminating food-allergen(s) presumed to be causing EoE and avoiding medications and their related side effects.²⁰ The three typical diets are the elemental diet, allergy test-directed elimination, and empiric elimination.

An elemental diet is an allergen-free diet. It involves consuming amino acid-based formulas as the sole source of nutrition. Although an elemental diet is about 91% effective in controlling eosinophilic inflammation in EoE, it has significant limitations. Some limitations include the formula's high cost, poor palatability, the long dietary reintroduction period, and frequent endoscopy (EGD) with biopsies to identify the food allergen.^21–23

An allergy test-directed elimination diet is based on eliminating food and aeroallergen, identified by either a serum IgE, skin prick, or atopy patch test. Although these tests are designed to identify antigens for immediate food hypersensitivity and other atopic conditions, such as asthma, atopic rhinitis, and eczema, they have shown very limited accuracy in identifying specific triggers for EoE in an individual. Dairy, egg, wheat, and soy are among the most common antigens identified through allergy tests in children, and most adults appear to be sensitized to peanuts, eggs, and soy.^24–26 A meta-analysis of 33 studies (including 1,317 individuals with EoE) reported a 45.5% success rate for an allergy test-based elimination diet, making this the least effective dietary elimination strategy and one that may be gradually falling out of favor in clinical practice.²⁷

An empiric elimination diet is the most well-studied and the most favored dietary elimination approach. It involves the elimination of foods, including dairy, egg, wheat, soy, nuts, and seafood, identified through epidemiologic studies, and are commonly associated with EoE. There are several ways to implement the empiric elimination diet.^28,29 It can be either one-food elimination (1FED, usually dairy with up to 68% cumulative efficacy), two-food elimination (2FED, usually dairy and wheat with 43% cumulative efficacy), four-food elimination (4FED, usually dairy, wheat, egg, soy with up to 71% cumulative efficacy), and six-food elimination (6FED, usually dairy, egg, wheat, soy, nuts, and seafood with incremental effectiveness of up to 78%).²⁷ Furthermore, one can employ an empiric elimination diet as a step-up (1FED, 2FED, 4FED, and 6FED) or a step-down approach (6FED, 4FED, 2FED, and 1FED) in clinical practice.³⁰ Once again, choosing which approach to pursue is typically based on the shared decision-making between the patient, their caregivers (or parents of pediatric patients), and their healthcare providers. CEGIR conducted a multi-site, randomized, prospective trial comparing 1FED (milk elimination) vs. 6FED (milk, wheat, fish, soy, nuts and egg).³¹ Interestingly, this study showed similar responses between 1FED and 6FED, both achieving ~40% remission rates. These findings provide a strong rationale for first starting with milk elimination therapy.

Pursuing a dietary elimination approach to identify triggering food allergen(s) can be expensive and time consuming and may require multiple endoscopies with biopsies to confirm treatment response or relapse of EoE. It may also be associated with growth issues and nutritional deficiencies, particularly in children.³² Furthermore, it can have unintended ramifications for the patients' and their caregivers' social and emotional well-being.³³

Drugs

The proton-pump inhibitors (PPIs) and topical corticosteroids (TCS) are currently the mainstays of the management of EoE. More recently, there has been immense interest in developing therapeutics targeting the specific molecules in the immunopathogenesis pathways to induce clinical improvement and histologic remission of EoE.

Proton-pump inhibitors

Many consider PPIs as first-line therapy since this medication has been used for a long time for non-EoE indications. Additionally, PPIs well-studied in EoE and are readily available and relatively easy to administer. It can be administered as a tablet, and for those who have difficulty swallowing a tablet, it can be administered as an oral solution, orodispersible tablets, or as granules mixed with applesauce. Once administered, the PPIs can induce gastric acid suppression, leading to a restoration of esophageal barrier function, inhibition of eosinophilic migration to the esophagus, inhibition of ATP12A, activation of the aryl hydrocarbon receptor, and reduction of STAT6 mediated eotaxin-3 (an eosinophil chemoattractant) expression.^34,35 It is now appreciated that the primary mechanism of PPI therapy in EoE is not related to acid suppression but rather the anti-inflammatory effect of this class of medicines. The histologic response rate for PPI therapy in children ranges between 23-83%, and in adolescents and adults, it ranges between 40-60%. The clinical response rate in children ranges between 23-82% and 48-72% in adults.³⁶ The current recommendation is 1-2 mg/kg/day, divided twice daily, with a maximum of 40 mg twice daily of esomeprazole and omeprazole and 30 mg twice daily of lansoprazole in children with EoE. For adults with EoE, it is 20-40 mg, once or twice daily. EGD with biopsies is recommended between 8-12 weeks to assess the treatment response.³⁷

The American Gastroenterological Association Joint Task Force EoE management guidelines recommend PPI therapy for patients with symptomatic esophageal eosinophilia, but this is a conditional recommendation with very little quality evidence. The available evidence is limited by the lack of placebo-controlled studies and heterogeneity in study design (patient selection and type, dose, and duration of PPIs). There are limited data on the efficacy of PPIs as a maintenance therapy for EoE.¹⁴ Between 13-60% of patients with EoE lose clinical response to PPIs over a 6-month to 2.9-year follow-up period. However, most experts agree that stepping down the PPI dose to the lowest dose possible that maintains remission is recommended. The United States Food and Drug Administration (FDA) has expressly cautioned people who use PPI standard doses on the risk of Clostridioides difficile infection, bone fractures, and hypomagnesemia. In addition, there is conflicting evidence for and against the association between the standard dose PPI use and the risk of pneumonia, other enteric infections, chronic kidney disease, dementia, cardiovascular events, and all-cause mortality.³⁸ However, one must be careful in interpreting these studies in the context of residual confounders and study designs.

Topical corticosteroids

The TCS can not only alleviate the eosinophilic inflammation in the esophageal epithelium, but also lower epithelial cell apoptosis, decrease esophageal molecular remodeling, reduce the dilated intercellular spaces, and downregulate mast cell activity.³⁹ The two most used TCS in clinical practice are budesonide^40–44 and fluticasone propionate.^45–47

Budesonide is commonly administered as a slurry (oral viscous Budesonide (OVB)) mixed with various ‘vehicles’, including sucralose, Neocate Nutra (a semi-solid, amino acid-based hypoallergenic formula), honey, and apple sauce.⁴⁸ Mixing with a vehicle of the patient’s choice allows for optimal consistency, adequate contact time with the esophageal mucosa, and palatability that can promote compliance to the medication.⁴⁹ Budesonide is also approved as an orodispersible tablet for induction and maintenance of remission of EoE by the European Medicine Agency.^44,50,51

Fluticasone propionate can be swallowed from a metered-dose inhaler (MDI), a diskus (a device containing medication as blister packs), or an oral viscous suspension. The most frequent method to administer Fluticasone is by MDI. The patient directly sprays medication into their mouth (without a spacer) and then swallows the aerosolized medication. They then rinse their mouth and spit it out to avoid any oral side effects. A video demonstration of this technique is available here. Although some retrospective studies have suggested that treatment with OVB leads to better endoscopic and histologic outcomes than fluticasone propionate,^52,53 prospective randomized clinical trials have shown that both OVB and fluticasone MDI produced a comparable significant improvement in dysphagia and endoscopic features and a decrease in esophageal eosinophilia.⁵⁴ Other TCS, although less commonly used, are ciclesonide^55–57, mometasone,⁵⁸ and beclomethasone.^59,60 Possible adverse effects of TCS preparations include local candida overgrowth, adrenal axis suppression, and concerns for suppression of height velocity.^61,62

Other medications, although very uncommonly used in clinical practice, include systemic steroids (prednisone)47 and mast cell stabilizers (cromolyn sodium)⁶³.

Biologics

With a greater understanding of the molecular mechanisms underlying EoE, limitations and side effects of existing therapeutic approaches, and advances in biotechnological methods, there is burgeoning interest in developing biologic therapies for EoE.

The first biologics tested for EoE were the antibodies against circulating IL-5, including mepolizumab and reslizumab.^64,65 The IL-5 is a cytokine that regulates eosinophils' development, differentiation, and survival, including eosinophil trafficking to the esophagus in EoE.66 In clinical trials, both mepolizumab and reslizumab significantly reduced esophageal eosinophil levels compared to a placebo. However, the clinical outcomes (physician global assessment scores) were not significantly better than the placebo.^65,67 Likewise, benralizumab, a monoclonal antibody targeting IL-5Rα-chain with cytotoxic effects on eosinophils, resulted in histologic remission, but the clinical response was heterogeneous (MESSINA trial).

In an open-label, pilot study, omalizumab, an anti-IgE antibody commonly used in IgE-mediated asthma and food allergies, showed early promise by inducing clinical and histologic remission in 33% of the 15 patients enrolled.⁶⁸ However, a follow-up randomized control trial in 30 patients showed that omalizumab did not offer a significant clinical benefit or histologic improvement compared with a placebo.⁶⁹ Likewise, infliximab, a chimeric IgG1 monoclonal antibody, and a potent tumor necrosis factor-α inhibitor with demonstrated efficacy in treating inflammatory bowel disease, including Crohn disease, has been used in adult patients with severe, corticosteroid-dependent EoE. However, in a prospective T1 translational study, infliximab in a standard induction dosage schedule did not induce histologic resolution nor improve the clinical symptoms. In addition, like omalizumab, it evoked heterogeneous reactions ranging from non-response to a mild flare-up.⁷⁰ There have been reports of the use of Vedolizumab, an anti-α4β7 integrin agent that inhibits leukocyte trafficking and mediates Th2 cytokine effects by binding with high affinity to eosinophils and CD4 T cells in patients. This was used in patients with Crohn disease and concomitant EoE with limited success.^71–73

In an initial study, AK002 (or lirentelimab), a siglec 8 inhibitor, led to histologic remission in 93% of patients with EoE compared to 11% in the placebo group and improved dysphagia in the EoE group compared to the placebo group.⁷⁴ Subsequently, in a phase 2/3, 24-week, randomized, placebo-controlled study of lirentelimab in patients with EoE, although a significant improvement in the histologic resolution was noted compared to the placebo group, the difference in the absolute mean change in the dysphagia symptom questionnaire score in the EoE group compared to the placebo group did not achieve statistical significance (KRYPTOS study). Finally, in a clinical trial, QAX576, a fully humanized anti-IL-13 monoclonal antibody, improved the esophageal intraepithelial eosinophilia, eotaxin-3, and periostin expression but did not significantly improve clinical symptoms compared to the placebo.⁷⁵

Currently, the biologics targeting IL-4 and IL-13, key and upstream Th2 cytokines central to EoE pathogenesis, are being extensively studied. In 2022, Dupilumab, a fully humanized monoclonal antibody that blocks IL-4 and IL-13 signaling, became the first FDA-approved medication for EoE, or any EGID. In the three-part, randomized, double-blind, placebo-controlled trials, Dupilumab administered subcutaneously at a weekly dose of 300 mg resulted in histologic remission and improvement in symptoms of EoE in adolescents (≥ 12 years and ≥ 40 kgs) and adults. The histologic improvement in every two-week dosing regimen was qualitatively like the weekly dosing regimen. However, the differences between the every two-week regimen and the placebo did not achieve statistical significance. Notably, impedance planimetry was studied as an exploratory endpoint, and Dupilumab therapy significantly improved esophageal distensibility by 18% compared with placebo. Injection site reaction (most common), upper respiratory infections, arthralgia, and conjunctivitis were some of the adverse events reported (PMID: 36546624). Although having an FDA-approved drug for EoE is a significant milestone, several important questions remain about the placement of Dupilumab in the treatment algorithm for EoE. For instance, can Dupilumab be used as first-line therapy for EoE instead of tried and tested approaches, such as PPI and TCS, and should the use of Dupilumab be limited to difficult-to-treat EoE cases?

There are several promising therapeutic options in the pipeline. Cendakimab (or CC-93538, previously RPC4046), a humanized monoclonal antibody blocking IL-13 and its binding to IL-13Ra1 and IL-13Ra2, has been shown to reduce esophageal eosinophilia, improve endoscopic features, and reduce clinical dysphagia in patients with EoE, particularly in patients with steroid-refractory EoE. A phase 2/3, multicenter, multinational, randomized, double-blind, placebo-controlled induction and long-term controlled study to evaluate the efficacy and safety of Cendakimab in adolescents and adults with EoE is currently underway (NCT04991935).

Etrsimod, an oral sphingosine 1-phosphate receptor modulating targeting multiple S1P receptors (S1P1, S1P4, and S1P5) with demonstrated effectiveness in improving clinical and endoscopic disease in moderate to severe ulcerative colitis, is currently being tested for safety and efficacy in EoE in phase 2, randomized, double-blind, placebo-controlled study (NCT04682639).

The levels of IL-15 and its receptor IL-15R alpha are increased six and ten-fold, respectively, in esophageal tissues in patients with EoE. Furthermore, IL-15 regulates immune responses, particularly at gastrointestinal mucosal interfaces. The safety, tolerability, pharmacokinetics, and pharmacodynamics of intravenous treatment of CALY-002, an anti-IL-15 antibody, in a cohort of healthy subjects and subjects with celiac disease and EoE is currently underway (NCT04593251).

Finally, Tezepelumab, an anti-TSLP monoclonal antibody that has shown promise in patients with uncontrolled asthma, has been granted Orphan Drug Designation in the US for EoE. A phase 3 trial to investigate the efficacy and safety of Tezepelumab in EoE is currently underway (NCT05583227).

Conceivably, one or more of these additional promising therapeutic options (see Table below) may soon become available for clinical use (in addition to the dupilumab). However, several factors, including the cost, accessibility, effectiveness, safety, and the duration of clinical and histologic response over time, will influence the use of biologics in clinical practice.

Table: Biologics currently being investigated for EoE

*Per ClinicalTrials.gov accessed on 01.13.2023; #TSLP: Thymic stromal lymphopoietin

Dilation

Currently, repeated EGD with biopsies is required for diagnosing and monitoring EoE. EGD also has a crucial therapeutic role in the management of esophageal strictures, EFIs, and related complications, including esophageal perforation and bleeding.

Esophageal strictures are graded as mild (> 9 mm in diameter) and moderate to severe (< 9 mm). A goal esophageal caliber of at least 16 mm in adolescents and adults is reported to relieve dysphagia and possibly decrease the likelihood of EFIs.⁷⁶ Although esophageal dilations are performed to manage esophageal strictures related to EoE, this alone may not treat the underlying eosinophilic inflammation that led to the stricture formation. Additional, concomitant treatment will be required to control the inflammation, increase the esophageal caliber, and potentially decrease the need for future dilations.⁷⁷

The techniques and approaches for endoscopic dilation have evolved over the years. However, existing techniques and approaches are considered safer and result in better-tolerated procedures. Balloon dilators are commonly used through the scope, followed by Savary dilators and Maloney dilators.^19,78 There is limited guidance regarding what type of dilator is best, and it largely depends on the endoscopist’s training, experience, preference, and comfort level.

EFI is relatively common in adolescents and adults with EoE. It can be the presenting symptom of EoE in up to 55% of patients, and a quarter of patients have recurrent food impactions.^79,80 An urgent or emergent flexible EGD to remove the lodged food is usually necessary, depending on whether there is complete or near a complete esophageal obstruction. En bloc, piecemeal, cap-assisted, and push techniques are different methods for managing EFIs.⁸¹ The push technique has been used in adults with a low risk of complications but has not been well described in children.^82,83 Various tools have been described for removing the impacted food, including forceps (rat tooth, alligator, and biopsy forceps), snare, retrieval net, tripod grasper, basket, and suction. More than one tool and technique may be required in complex cases. For example, an overtube in older children can limit mucosal trauma if multiple passes are needed.⁸⁴ Regardless of the tool(s) and/or technique(s) used to remove the impacted food, it is strongly recommended that multiple biopsies (away from the site of impaction) be obtained after removal, given the strong association between esophageal food impaction and EoE and the requirement for histologic confirmation of the diagnosis.⁸⁵ Mucosal friability related to active inflammation and esophageal remodeling may place individuals with EFI at an increased risk of perforation and bleeding during the removal of the impacted food bolus or dilation of esophageal strictures.⁸⁶ Typically, these complications are managed conservatively. Rarely, metal esophageal stents, endoscopic clips, and surgical interventions may be indicated. No deaths have been reported related to either esophageal perforation or therapy.⁸⁷

Leveraging complex data and Precision medicine

With a robust understanding of the genetic underpinnings and molecular mechanisms of EoE, the treatment and prevention strategies can perhaps be tailored for each EoE patient using artificial intelligence or machine learning.⁸⁸ For instance, how the pharmacogenetic variants influence PPI response (e.g., CYP2C19*17) and PPI pharmacodynamics (e.g., STAT6 rs324011 is associated with a 6.1-fold increased risk of failure to achieve a complete remission with PPI therapy) has already been reported.^89,90 There have been attempts at identifying molecular endotypes of patients with EoE.⁹¹ Phenotypic classifications (fibrostenotic phenotype) have also shown promise in predicting response to PPI both in the induction and maintenance phases.⁹² In addition, esophageal microRNAs in the esophageal biopsies appear to discriminate between PPI responders and non-responders at baseline.⁹³ Response to diet therapy may be predicted by baseline levels of milk-specific IgG4.⁹⁴

Conclusion

EoE is an increasingly prevalent, chronic, and progressive disease affecting all ages worldwide. Dietary elimination of food allergens, drugs including biologics, and esophageal dilation are the prevailing treatment options. However, new therapeutic targets are being discovered and this is promoting development of novel therapies for EoE. It is conceivable that soon we will transition from a 'one fits all' approach to a 'precision medicine' approach wherein the phenotype and the endotype of a patient with EoE would guide the patient's treatment.

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