Alimentary Tract
Older patients with eosinophilic esophagitis have high treatment response to topical steroids

https://doi.org/10.1016/j.dld.2021.10.004Get rights and content

Abstract

Background

There are few data assessing treatment response in older eosinophilic esophagitis (EoE) patients and we evaluated treatment outcomes to topical corticosteroids (tCS) in this older population.

Methods

This retrospective cohort study of the UNC EoE Clinicopathologic database included subjects with a new diagnosis of EoE treated with tCS. Histologic responses, global symptom response, and endoscopic changes were recorded. Older EoE patients (≥65 years) were compared to younger EoE patients (<65).

Results

We identified 467 EoE patients treated with tCS, 12 (3%) of whom were ≥65 years. Compared to those <65 years, patients ≥65 had longer symptom duration and worse endoscopy scores, but most clinical features were similar. Post-treatment peak eosinophil counts trended higher in the <65 group (25.0 vs 5.5; p = 0.07). Histological response was greater in the ≥65 population at <15 eos/hpf (92% vs 57%; p = 0.02), ≤6 eos/hpf (83% vs 50%; p = 0.02), and <1 eos/hpf (58% vs 29%; p = 0.03). Older age was independently associated with increased odds of histologic response (adjusted OR 8.48, 95% CI: 1.08–66.4).

Conclusions

EoE patients ≥65 years had a higher likelihood of responding to tCS therapy, suggesting they should be studied more closely and included in future trials.

Introduction

Eosinophilic esophagitis is a chronic immune/antigen-mediated clinicopathologic disease that impacts patients of all ages [1,2]. Because of symptoms, complications, and impact on quality of life, EoE results in a significant upper gastrointestinal morbidity and disease burden [3,4]. Over time, the esophageal inflammation may progress to a fibrostenotic phenotype, leading to more stricturing, dysphagia, and food impaction symptoms [5], [6], [7], [8]. Treatments for EoE can include proton-pump inhibitors, topical steroids, dietary elimination, and esophageal dilation [9,10]. While there are no FDA approved medications for the treatment of EoE in the U.S., a topical steroid has been approved in Europe and Canada, and multiple novel therapies are being explored [11], [12], [13], [14], [15], [16], [17].

Data suggest that EoE is increasing in incidence and prevalence with peak prevalence seen between the ages of 30–39 years old, with a subsequent decreased incidence as age increases [18]. With this and given that older EoE patients may have had the disease longer preceding diagnosis, elderly patients may be at risk for more severe fibrostenosis and less symptom response [19]. However, recent clinical trials have limited the upper age for inclusion. For example, trials of budesonide oral suspension capped the upper age at 40 or 55 years [14,15,20,21], two trials of biologics were capped at age 65 [12,17], and while a trial evaluating budesonide orodispesible tablets included patients aged 18–75, the average age was 37 years [16]. As such, the elderly EoE cohort, including their response to treatment, is poorly described.

Because EoE is chronic, the EoE patient population will age and be comprised of more elderly patients, making the disease more prevalent in the older population. The limited data exploring the older EoE population's use of topical corticosteroids (tCS) is a knowledge gap, and it is unknown whether they respond differently than non-elderly cohorts. Therefore, the aim of this study was to determine treatment outcomes to tCS in older EoE patients compared to younger EoE patients.

Section snippets

Methods

We conducted a retrospective cohort study of the University of North Carolina (UNC) EoE Clinicopathologic database, which has been previously described [22], [23], [24], [25], [26]. In brief, this database includes data from newly diagnosed EoE cases of all ages based on consensus guidelines at the time of their diagnosis [1], [2], [3],12]. For this study, patients were included if they had documented tCS treatment per clinical protocols and a follow-up endoscopy with biopsy to assess treatment

Baseline characteristics and comparison of <65-year-old cohort to ≥65-year-old cohort

We identified 467 newly diagnosed EoE patients who met inclusion criteria with tCS treatment. The overall mean age was 29 years old, with 152 patients (33%) under 18 years old and 12 patients (3%) 65 years or older (Table 1). The majority of the patients were Caucasian (83%), and 68% were male. Atopy, dysphagia symptoms, and typical endoscopic findings of EoE were also common. Comorbidities in the elderly subgroup included hypertension (58%), dyslipidemia (50%), benign prostatic hypertrophy

Discussion

EoE impacts patients of all ages and leads to significant morbidity and disease burden [1], [2], [3], [4]. Several modalities have been studied for the treatment of EoE, but topical steroids are the only treatment given a “strong” recommendation in recent guidelines [9,10]. Currently, scant data exist on treatment response in elderly EoE patients. Our main findings were that while patients ≥65 years old represented a relatively small proportion of EoE, they had a significantly higher histologic

Declaration of Competing Interest

Dr. Dellon is a consultant for Abbott, Abbvie, Adare/ Ellodi, Aimmune, Allakos, Amgen, Arena, AstraZeneca, Avir, Biorasi, Calypso, Celgene/Receptos/BMS, Celldex, Eli Lilly, EsoCap, GSK, Gossamer Bio, Holoclara, Landos, Morphic, Nutricia, Parexel/Calyx, Regeneron, Revolo, Robarts/Alimentiv, Salix, Sanofi, Shire/Takeda, receives research funding from Adare/Ellodi, Allakos, Arena, AstraZeneca, GSK, Meritage, Miraca, Nutricia, Celgene/Receptos/BMS, Regeneron, Shire/Takeda, and has received an

Grant Support

This study was supported by NIH T35 DK007386 and T32 DK007634.

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