Management of refractory eosinophilic oesophagitis

Abstract

The goal of this Review is to discuss the clinical approach to patients who do not respond to treatment for eosinophilic oesophagitis (EoE). Refractory EoE is challenging to manage as there are limited data to guide decision-making. In this Review, refractory EoE is defined as persistent eosinophilia in the setting of incomplete resolution of the primary presenting symptoms and incomplete resolution of endoscopic findings following a PPI trial, and after treatment with either topical steroids or dietary elimination. However, this definition is controversial. This Review will examine these controversies, explore how frequently non-response is observed, and highlight potential explanations and predictors of non-response. Non-response is common and affects a large proportion of patients with EoE. It is important to systematically assess multiple possible causes of non-response, as well as consider treatment complications and an incorrect diagnosis of EoE. If non-response is confirmed, second-line treatments are required. Although the overall response rate for second-line therapy is disappointing, with only half of patients eventually responding, there are several promising agents that are currently under investigation, and the future is bright for new treatment modalities for refractory EoE.

Figure 1 |. Endoscopic appearance of refractory EoE.

Paired endoscopic images of the oesophagus of a patient with eosinophilic oesophagitis (EoE) at diagnosis (part a) and after treatment with oral viscous budesonide at a dose of 1 mg twice daily (part b). At both time points, the patient remained symptomatic with dysphagia and there is no change in either the endoscopic findings (oedema (a diffuse loss of vascular markings), rings (arrowheads), subtle exudates (asterisks) and furrows (arrows) are seen at both time points) or histological findings (60 eos/hpf at diagnosis and 55 eos/hpf post-treatment). Eos/hpf, eosinophils per high-power field.

Figure 2 |. Clinical approach to refractory EoE.

A suggested treatment algorithm for patients with eosinophilic oesophagitis (EoE) after a PPI trial who do not respond to a either topical steroid or dietary elimination treatment. When a patient might have non-response, the first step is to evaluate the potential causes of non-response and correct them. If non-response is confirmed, the next step will depend on the initial treatment strategy. If the original treatment was with topical steroids, then this modality could be optimized or the patient could be switched to dietary elimination. If the original treatment was dietary elimination, this could be maximized or the patient could be treated with topical steroids. If there is continued non-response, there are a wide range of options the choice of which will depend on the patient and disease characteristics. Often these patients are suitable candidates for participation in clinical trials of emerging treatment agents.