Introduction

Eosinophilic oesophagitis (EoE) is a chronic, immune-mediated disease of the oesophagus. EoE is associated with a substantial disease burden affecting the quality of life and impact mental health. There are limited data describing the incidence of psychiatric disorders and the use of psychotropic drugs (PDs) in EoE patients.

Aims & Methods

The aim was to investigate whether EoE patients in Denmark, after being diagnosed, have a higher incident use of psychotropic drugs and more psychiatric comorbidity compared to the general population. This study is a nationwide, population-based register study including 3,367 EoE patients and 16,835 age- and sex-matched comparators. A register-based EoE definition was used to identify cases. Incident PD use was extracted from the prescription register and information regarding psychiatric contacts was retrieved from the Danish Psychiatric Central Research Register.

Results

The five-year incidence of PD use in EoE patients was 13.8% compared to 7.1% of the matched comparators (HR 1.83; CI 1.6-2.0; P ≤ 0.001). Antidepressants were the most frequently prescribed PD, whereas antipsychotics were the least prescribed PD. Increasing age, lower educational level, and comorbidity (Charlson Comorbidity Index score ≥1) were associated with the prescription of PDs. The risk of PD use was lower in men compared to women with EoE.

Conclusion

Treatment with PDs were 94% more common in EoE patients after they were diagnosed than in the general Danish population, indicating that EoE patients have an increased risk of psychiatric disorders.

References

de Rooij WE, Bennebroek Evertsz’ F, Lei A, Bredenoord AJ. Mental distress among adult patients with eosinophilic esophagitis. Neurogastroenterology and Motility. 2021;33(7).
Reed CC, Corder SR, Kim E, Sanders E, Tappata M, Eluri S, et al. Psychiatric Comorbidities and Psychiatric Medication Use Are Highly Prevalent in Patients with Eosinophilic Esophagitis and Associate with Clinical Presentation. American Journal of Gastroenterology. 2020;115(6):853–8.
Röjler L, Garber JJ, Butwicka A, Roelstraete B, Ludvigsson JF. Individuals With Eosinophilic Esophagitis Are at Greater Risk of Later Psychiatric Disorder. American Journal of Gastroenterology. 2022;117(7):1046–55.
Taft TH, Guadagnoli L, Edlynn E. Anxiety and Depression in Eosinophilic Esophagitis: A Scoping Review and Recommendations for Future Research. J Asthma Allergy. 2019; 12:389–99.
Jensen ET, Aceves SS, Bonis PA, Bray K, Book W, Chehade M, et al. High Patient Disease Burden in a Cross-sectional, Multicenter Contact Registry Study of Eosinophilic Gastrointestinal Diseases. J Pediatr Gastroenterol Nutr. 2020;71(4):524–9.
Taft TH, Kern E, Keefer L, Burstein D, Hirano I. Qualitative Assessment of Patient-reported Outcomes in Adults With Eosinophilic Esophagitis. J Clin Gastroenterol. 2011; 45:769–74.

Disclosure

The authors declare that there is no conflict of interest.

Introduction

A low incidence of eosinophilic esophagitis (EoE) in children in the North Denmark Region (NDR) were measured in 2007-2017. Few of the children diagnosed before 2017 were treated to remission suggesting a lack of awareness. While there currently are no guidelines for treating EoE in Denmark, a new English guideline was published in 2022 renewing focus on the disease.

Aims & Methods

The aim of this study was to measure the difference of current Danish clinical practice for treatment and follow-up of EoE children in the NDR with the new English guideline from the British Society of Gastroenterology (BSG) and the British Society of Pediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN). This retrospective, register-based DanEoE cohort study included 31 children diagnosed with EoE between 2007–2021 in NDR. Medical records were reviewed and information about treatment and follow-up were collected.

Results

In 32% of the children with EoE in the NDR, first-line treatment initiated corresponded with the recommendations in the new English guideline. One in 6 children were never started on any treatment even though treatment always is recommended. Symptomatic follow-up was completed in 77% (24/31) of children and 85% (11/13) of the children after 2017. Histologic follow-up within 12 weeks was completed in 13% (4/31) of the children and 15% (2/13) of the children after 2017. Combined symptomatic and histologic remission after first-line treatment was achieved in 6% (2/31).

Conclusion

In Denmark focus on improving EoE treatment and follow-up for children is needed, as there is a significant difference between current clinical practice and the recommendations in the new English guideline.

References

Hollænder M, Terkelsen JH, Kramme F, Bredal K, Kragholm K, Dalby K, et al. The incidence of eosinophilic oesophagitis in 2007-2017 among children in North Denmark Region is lower than expected. BMC Pediatr. 2022 Apr;22(1):183.
Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, et al. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut. 2022 Aug;71(8):1459–87.

Introduction

Danish national guidelines recommend a diagnostic upper endoscopy within 2 weeks after food bolus obstruction (FBO). Firstly to search for possible upper gastro-intestinal (GI) cancer (national cancer guideline), and if cancer is excluded to sample 8 biopsies to exclude eosinophilic oesophagitis (EoE) (EoE guideline). In the clinical work in our Department of Emergency Medicine in Denmark there is a growing suspicion that these nationale guidelines are not always followed.

Aims & Methods

The aims of this study were to 1) describe the causes of FBO, 2) to determine the proportion of patients who underwent upper endoscopy with biopsies according to guideline, and 3) to identify ICD10 diagnosis and procedure codes applied to the hospital visits due to FBO in the North Denmark Region (NDR). This was a registry based study og the entire population of the North Denmark Region of 580,000 citizens. For all acute hospital visits in the NDR in 2021, medical registries were used to find patients with FBO, and their medical records were reviewed. All hospital visits with ICD 10 codes possibly reflecting FBO, and a sample of 14400 hospital visits with unspecific ICD codes (R and Z codes) were screened for possible FBO. Diagnosis, follow up, and treatment were recorded for all patients with FBO.

Results

Of 1886 hospital visits where registry ICD codes possibly reflected FBO 8.4% were due to FBO, while FBO were present in 0.028% in a sample of 14400 hospital visits with ICD codes of unspecific nature. The median age for a patient presenting with FBO at the hospital was 66.0 (49.8-81.0) years, and 55 % had experienced FBO before. Effective treatment of FBO only involved endoscopic removal in half of patients​​​​Thirty percent did not undergo upper endoscopy within 2 weeks of the hospital visit (upper cancer guideline), and 51% were never biopsied in the oesophagus (EoE guideline). Most patients (65.1%) were never diagnosed with a cause of FBO.

Conclusion

More than half of patients hospitalized due to FBO in NDR in 2021 were never diagnosed with a cause. In one third the national cancer guidelines were not followed, and in half of the cohort EoE guidelines were not followed. There is a real risk of undetected upper GI cancers and EoE as consequence and the area needs focus in Denmark to improve patient treatment and prevent new FBO.

References

Andersen IB, Bremholm L, Havelund T, Jørgensen SP, Lund Krarup A, Mohammadi M, et al. Eosinofil øsofagitis [Internet]. Dansk Selskab for Gastroenterologi og Hepatologi. 2020 [cited 2023 Mar 13]. Available from: https://dsgh.dk/wp-content/uploads/2022/06/EoE.pdf
6. Sundhedsstyrelsen. Pakkeforløb for kræft i spiserør, mavesæk og mavemund [Internet]. 2016 [cited 2023 Mar 26]. p. 11. Available from: https://www.sst.dk/-/media/Udgivelser/2016/Kraeft-Spiseroer-mavesaek-mavemund/Pakkeforloeb-for-kraeft-i-spiseroer-mavesaek-og-mavemund.ashx?sc_lang=da&hash=6645435FD019F6FCAD974D027B4402DB

Introduction

Eosinophilic oesophagitis (EoE) is a chronic, progressive type 2 inflammatory disease. Proton-pump inhibitors (PPIs), swallowed topical corticosteroids (STCs), and elimination diets have been used as standard treatments for EoE patients. However, the real-world evidence (RWE) highlighting disease burden in Europe are limited.

Aims & Methods

To assess disease burden and treatment patterns among adolescent and adult patients with EoE in real-world practice.
Medical records were retrospectively reviewed for patients (aged ≥12 years) who were newly diagnosed with EoE between 1 January 2009 and 31 December 2019 (index) in Germany, France, Spain, and the United Kingdom. Patients with a peak eosinophil (eos) count (PEC) of ≥15 eos/hpf within 90 days of the index date and ≥1 follow-up endoscopy within 24 months of the index date were included. Demographics, clinical features, treatment patterns, and health outcomes were assessed from the 12-month pre-index period to the last medical record entry or death. Disease progression was assessed via physician-defined (based on symptoms, endoscopy findings, histology, need for dilation, and food impaction) and proxy-reported outcomes (dilation performed, strictures, dysphagia, evidence of food impaction, treatment initiation in treatment-naïve patients and switching/augmentation).

Results

Overall, 385 patients were included, with 70.1%–78.1% being male; the mean age was 27.8 to 33.9 years. At EoE diagnosis, the PEC was 35.3–46.1 eos/hpf, the endoscopic appearance of the oesophagus was abnormal in 73.7%–85.6% of patients, and dysphagia was present in 59.8%–82.8% of patients. Most of the patients across all 4 countries were treated with PPIs (61.5%–91.8%), STCs (56.7%–82.3%) and elimination diets (41.4%–55.2%) after EoE diagnosis. Of the patients with available data, abnormal histology (≥15 eos/hpf) was reported in 44.8%–72.0% of patients during the first 5 years after EoE diagnosis. The abnormal endoscopic appearance of the oesophagus was observed in 34.6%–83.3% of patients after approximately 2 years of EoE diagnosis and dysphagia was present in 10.2%–25.0% of patients after 4 years of EoE diagnosis across all 4 countries. While physician-defined disease progression occurred in 6.1%–16.1% of patients, 19.4%–35.1% of patients experienced proxy-reported outcomes of potential disease progression (including oesophageal dilation performed in 10.8%–21.7% of patients) after EoE diagnosis. An overview of patient and clinical characteristics at EoE diagnosis and treatment patterns and disease progression (physician-defined and proxy-reported) after EoE diagnosis across Germany, France, Spain, and the United Kingdom is provided in the Table.

Conclusion

Adolescent and adult patients with EoE chronically experienced substantial disease burden. A subset demonstrated disease progression, perhaps underrecognised despite treatment with PPIs, STCs, and elimination diets. Hence, successful EoE management may include proactive disease monitoring, treating underlying pathophysiology and prescribing maintenance therapies to achieve long-term clinical remission.

References

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Disclosure

Ulrike von Arnim: Consulting and/or speaker fees from Dr. Falk Pharma, Sanofi, Astra Zeneca, EsoCap, Abbvie, Janssen, Takeda, Pfizer, Bristol Myers Squibb.
Frank Zerbib: Consulting and/or speaker fees from Sanofi, Dr Falk pharma, Bristol Myers Squibb, Bioprojet, AstraZeneca.
Tiffany Pela, Juby A. Jacob-Nara, Gaelle Le-Bagousse-Bego, Sarette T. Tilton: Employees of Sanofi; may hold stocks and/or stock options in the company.
Bram P. Raphael, Amr Radwan, Ryan B. Thomas: Employees of Regeneron Pharmaceuticals, Inc.; may hold stocks and/or stock options in the company.
Rohan C. Parikh, Fareedat Bello: Employees of RTI Health Solutions, which received research funding from Sanofi to design and execute this study.
Funding: This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.
Acknowledgement: Medical writing support was provided by Akshata Rao and Ali Nasir Siddiqui, PhD, of Sanofi.

Introduction

Eosinophilic oesophagitis (EoE) is a chronic progressive type 2 inflammatory disease clinically characterized by oesophageal dysfunction symptoms (dysphagia, food impaction, odynophagia, chest discomfort) and histologically by eosinophil predominance.^1-3 The global incidence and prevalence of EoE are increasing; therefore, real-world data can aid in identifying current disease management challenges.

Aims & Methods

Aim: This study aimed to describe demographics, clinical features, treatment patterns, health outcomes, and healthcare resource utilization (HCRU) among real-world patients with EoE.
Methods: We analysed medical record data collected from a multinational cohort of EoE patients diagnosed between January 1, 2009, and December 31, 2019. Physicians from Canada, France, Germany, Spain, and the United Kingdom provided data for eligible patients aged ≥12 years with an eosinophil (eos) count ≥15 eos/hpf within 90 days of diagnosis and at least one follow-up endoscopy within 24 months. We collected data on patient demographics, clinical characteristics, treatment patterns, outcomes, and HCRU. Patients were followed until their last medical record entry or death, whichever occurred first. Outcomes are from three-year follow-up period from the index date. Descriptive statistics were employed to estimate continuous variables and categorical variables.

Results

This study included 415 patients diagnosed with EoE, with a mean age of 31.8 ± 14.6 years. The majority of patients were white (91.8%) and male (74.0%). The average (±SD) follow-up duration was 5.2 (±3.2) years post-EoE diagnosis. The mean (±SD) delay between symptom onset and the diagnosis was 3.4 (±4.8) years. At EoE diagnosis, the mean (±SD) peak eosinophil count was 41.4 (±43.4) eos/hpf and endoscopic abnormalities were found in 80.2% of patients. After EoE diagnosis, patients were treated with proton pump inhibitors (PPIs) (77.1%), swallowed topical corticosteroids (STCs) (68.2%), dietary modifications (48.4%), oesophageal dilation (18.8%), and systemic corticosteroids (10.8%). At third-year follow-up (n = 392), patients continued to experience dyspepsia (20.4%), heartburn (23.5%), dysphagia (24.5%), and food impaction (5.4%) despite treatment. A relatively small percentage of patients achieved histologic remission during the first 5 years after EoE diagnosis; 4.1% with ≤1 eos/hpf (mean time to histologic remission [±SD]: 2.0 [±1.3] years), 20.0% with ≤6 eos/hpf (1.5 [±1.2] years), and 42.4% with <15 eos/hpf (1.4 [±1.1] years). During follow-ups, 98.8% (first year) and 97.3% (third year) of patients had at least one office visit, and 39.9% (first year) and 25.6% (third year) had at least one consultation with an allergist/immunologist.

Table 1. Overview of treatment patterns after eosinophilic oesophagitis diagnosis

Conclusion

This study highlights a significant delay in diagnosing EoE from the onset of symptoms. Along with PPIs and dietary modifications, a high percentage of patients received STCs and oesophageal dilation, indicating a substantial burden. Despite these treatments, optimal histologic remission rates and symptomatic control remain unmet needs. Addressing EoE burden necessitates developing strategies for earlier diagnosis and additional therapies to improve long-term management.

References

1. Mansoor E, Cooper GS. The 2010-2015 Prevalence of Eosinophilic Esophagitis in the USA: A Population-Based Study. Dig Dis Sci. 2016;61(10):2928-2934. doi:10.1007/s10620-016-4204-4.
2. Lu M, Goodwin B, Vera-Llonch M, Williams J. Disease Burden and Treatment Patterns Associated With Eosinophilic Esophagitis in the United States: A Retrospective Claims Study. J Clin Gastroenterol. 2022 Feb 1;56(2):133-140. doi: 10.1097/MCG.0000000000001491. PMID: 33443967; PMCID: PMC8754098.
3. Katzka DA. Eosinophilic Esophagitis. Ann Intern Med. 2020;172(9):ITC65-ITC80. doi:10.7326/AITC202005050.

Disclosure

CM has received consulting fees from AbbVie, Alimentiv, Amgen, AVIR Pharma Inc, BioJAMP, Bristol Myers Squibb, Celltrion, Ferring, Fresenius Kabi, Janssen, McKesson, Mylan, Pendopharm, Pfizer, Prometheus Biosciences Inc., Roche, Sanofi, Takeda, Tillotts Pharma; speaker's fees from AbbVie, Amgen, AVIR Pharma Inc, Alimentiv, Bristol Myers Squibb, Ferring, Fresenius Kabi, Janssen, Organon, Pendopharm, Pfizer, Takeda; royalties from Springer Publishing; research support from Ferring, Pfizer.
TP, JJN, KB, and STT are employees and stockholders of Sanofi.
AR, AK and RBT are employees and stockholders of Regeneron Pharmaceuticals, Inc.
RP is a full-time employee of RTI Health Solutions, which received research funding from Sanofi to perform this study. RTI Health Solutions is a unit of Research Triangle Institute, an independent, non-profit, research organization that does work for government.