Treatment Patterns in Patients With Eosinophilic Oesophagitis Referred for Expert Consultation
Authors
Sydney F. Pomenti, et al.
Paper of the Month – Selected and discussed by Arjan Bredenoord
🎯 Study Aim
Eosinophilic esophagitis (EoE) patients are frequently referred to tertiary centres for treatment refractory disease. The author of this paper explored expert perspectives on patients referred for refractory EoE, including its causes, prevalence, and evaluation.
🔬 Methods
The paper reports the results of an anonymous and blinded cross- sectional survey of international EoE experts assessing provider characteristics and their view on referral patterns, perceived causes of treatment failure, diagnostic approaches, and prior therapies in patients referred with refractory EoE.
📊 Key Findings
Fifty/two experts responded, these were predominantly gastroenterologists (77%) and practiced in academic settings (87%) with high EoE volume. Experts estimated that true refractoriness to medical therapy was 15% and 31% for dietary treatment. Patients referred for perceived refractory EoE had been treated with PPIs (80%), topical steroids (55%), and elimination diets (45%) while only 10% was tried on dupilumab. Half of the patients referred had been on combination therapy. After referral, experts focused on improving medication adherence (98%), dosing (92%), and administration technique (90%), while patients were evaluated with endoscopy (85%) and performing esophageal dilation (42%). The causes of perceived refractory disease were subtherapeutic dosing (34%), incorrect medication administration (30.5%), inappropriate medication choice (26.5%), and dietary non- adherence (26%). Functional and behavioural contributors including coexisting esophageal hypersensitivity (20%), ARFID (9%), and rumination syndrome (5%) were also reported as contributors to therapy non-response.
🧠 Interpretation
This study shows that the definition of EoE treatment refractory is variable, and previously tried therapies aren’t always being applied to a maximal extend when patients are referred as being treatment refractory. Also, the results of this study suggest that symptoms due to non-EoE conditions such as ARFID and rumination may be present and contribute to the perception of EoE non-response.
⚠️ Critical Appraisal
The study reflects the opinion of experts, which may be biased is influenced by their own practice pattern and case mix. Also, the degree of refractoriness is influenced by the availability of therapies, as certain budesonide formulations and dupilumab are not available for all patients in all regions.