Introduction
Eosinophilic Esophagitis (EoE) is a chronic, immune-mediated disease of the esophagus that, if not adequately treated, may progress to fibrostenotic complications. Current management relies on repeated esophagogastroduodenoscopy (EGD) with biopsies to evaluate histological remission. Standard guidelines recommend a follow-up EGD 8–12 weeks after initiating therapy to confirm efficacy. Given that each treatment change necessitates a new histological evaluation, identifying strategies that minimize the endoscopic burden is crucial for improving patient quality of life and reducing costs. Moreover, additional EGDs may be required during follow-up for reasons including symptom recurrence and need for dilations.
Aims & Methods
A multicenter retrospective analysis was conducted on a cohort of adult patients with diagnosed EoE since 2022 with a minimum follow-up of 12 months. The study compared the impact of different treatments on the endoscopic burden, defined as the number of additional EGDs required beyond the standard procedure used to verify treatment response. Patients who underwent multiple lines of therapy due to non-response were included more than once in the respective treatment groups. This approach was based on the assumption that an effective response would have clinical benefit by avoiding the need for further rescue treatments and their associated endoscopic monitoring.
Results
Forty-four patients were included in the study (75.0% males), with a median age at diagnosis of 33 years (interquartile range, IQR = 24-46 years), a median diagnostic delay of 30 months (IQR 10-63 months) and a median Index of Severity for Eosinophilic Esophagitis (I-SEE) score at diagnosis of 6 (IQR 5-7). Overall, 67 treatment courses were analyzed (44 first-line, 22 second-line, 1 third-line): 31 on orodispersible budesonide, 33 on PPI, and 3 on dairy-free diet (DFD). Baseline characteristics, including age, sex, endoscopic reference score (EREFS) and I-SEE score were similar across groups (p = n.s.). The number of additional EGDs was significantly higher in the PPI group compared to the budesonide group (p < 0.0001). Specifically, 69.7% of PPI-treated cases required at least one additional EGD (45.4% one, 18.2% two, and 6.1% three), whereas only 9.7% of budesonide-treated patients required further procedures (6.5% one, 3.2% two). In the DFD group, one patient (33.3%) required an additional EGD. Histological remission was achieved in 93.6% of the budesonide-treated cases, compared to 33.3% in both the PPI and DFD groups (p < 0.0001). Clinical response rates were also higher with budesonide (93.6%) than with PPI (63.6%) and DFD (66.7%, p = 0.008). At multivariable logistic regression, the presence of esophageal strictures at diagnosis was the only factor independently associated with an increased number of follow-up EGDs (p = 0.01).
Table 1: Number of additional EGDs and histological remission rates by treatment
| Treatment | Additional EGDs, n (%) | Histological remission, n (%) |
|---|
| 0 | 1 | 2 | 3 |
|---|
| Budesonide (n=31) | 28 (90.3) | 2 (6.5) | 1 (3.2) | 0 (0.0) | 29 (93.6) |
| DFD (n=3) | 2 (66.7) | 1 (33.3) | 0 (0.0) | 0 (0.0) | 1 (33.3) |
| PPI (n=33) | 10 (30.3) | 15 (45.4) | 6 (18.2) | 2 (6.1) | 11 (33.3) |
EGD = esophagogastroduodenoscopy; DFD = dairy-free diet; PPI = proton pump inhibitors.
Conclusion
Treatment with orodispersible budesonide was associated with a significantly lower endoscopic burden and higher histological remission rates during follow-up compared to PPI and dietary strategies, potentially reducing the overall clinical and procedural impact in patients with EoE.
References
- de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, et al. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis. 2024 July;56(7):1173–84.
- Lucendo AJ, Gutiérrez-Ramírez L, Tejera-Muñoz A, Molina-Infante J, Arias Á. Proton Pump Inhibitors for Inducing and Maintaining Remission in Eosinophilic Esophagitis: An Updated Systematic Review and Meta-Analysis. Clinical Gastroenterology and Hepatology. 2025 Nov 1;23(12):2115-2127.e21.
- Lucendo AJ, Miehlke S, Schlag C, Vieth M, von Arnim U, Molina-Infante J, et al. Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial. Gastroenterology. 2019 July;157(1):74-86.e15.
- Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: Validation of a novel classification and grading system. Gut. 2013 Apr;62(4):489–95.
- Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, et al. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology. 2022 Jul;163(1):59–76. doi:10.1053/j.gastro.2022.03.025 PubMed PMID: 35606197; PubMed Central PMCID: PMC9233087.
Disclosure
Giovanni Aldinio has served as consultant for Dr Falk. Edoardo Vincenzo Savarino has served as speaker for Abbvie, Aboca, Abivax, Agave, AGPharma, Alfasigma, Apoteca, Biosline, CaDiGroup, Celltrion, Dr Falk, EG Stada Group, Eli Lilly, Fenix Pharma, Galapagos, Giuliani, Johnson&Johnson, JB Pharmaceuticals, Innovamedica/Adacyte, Lionhealth, Malesci, Mayoly Biohealth, Montefarco, Novartis, Omega Pharma, Pfizer, Rafa, Reckitt Benckiser, Recordati, Sandoz, Sanofi/Regeneron, SILA, Takeda, Tillots, Unifarco; has served as consultant for Abbvie, Alfasigma, Apogee, AstraZeneca, Biogen, Bristol-Myers Squibb, Celltrion, Dr. Falk, Eli Lilly, Fenix Pharma, Ferring, Giuliani, Grunenthal, Johnson&Johnson, JB Pharmaceuticals, Merck & Co, Nestlè, Pfizer, PRO.MED.CS Praha a.s., Reckitt Benckiser, Recordati, Sanofi/Regeneron, SILA, Takeda, Unifarco; he received research support from Bonollo, Difass, Pfizer, Reckitt Benckiser, Sanofi/Regeneron, SILA, Unifarco, Zeta Farmaceutici.
