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  • Review Article
  • Published:

Management of refractory eosinophilic oesophagitis

Nature Reviews Gastroenterology & Hepatology volume 14, pages 479–490 (2017)Cite this article

Subjects

Key Points

  • Refractory eosinophilic oesophagitis (EoE) can be defined as persistent eosinophilia with incomplete symptom resolution, and persistent endoscopic findings after a PPI trial and after topical steroid treatment or dietary elimination

  • Depending on the treatment modality, non-response to topical steroid or dietary elimination in EoE can be in the range of 20–50%

  • Following non-response, it is important to systematically assess for explanations (for example, non-adherence; incorrect dosing, formulation or administration; ongoing allergen or food trigger exposure; inadequate dietary elimination; and validity of original diagnosis)

  • Few clinical predictors of non-response have been identified to date

  • Topical steroid or dietary elimination treatments should be maximized before switching between treatment modalities

  • Second-line treatment options include systemic corticosteroids, elemental formula, leukotriene antagonists, immunomodulators and experimental agents in clinical trials

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.

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Figure 1: Endoscopic appearance of refractory EoE.
Figure 2: Clinical approach to refractory EoE.

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Acknowledgements

E.S.D. is supported, in part, by the US National Institutes of Health (NIH; grant R01 DK101856), as well as the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR; grant U54AI117804), which is part of the Rare Disease Clinical Research Network (RDCRN), an initiative of the Office of Rare Disease Research (ORDR), the US National Center for Advancing Translational Sciences (NCATS), and is funded through collaboration between the US National Institute of Allergy and Infectious Diseases (NIAID), the US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and NCATS.

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  1. Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, 27599–7080, North Carolina, USA

    Evan S. Dellon

  2. Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Diseases, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, 27599–7080, North Carolina, USA

    Evan S. Dellon

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E.S.D. is a consultant for Adare, Alivio, Banner, GlaxoSmithKline, Receptos, Regeneron and Shire. He has received research funding from Meritage, Miraca Life Sciences, Nutricia, Receptos, Regeneron and Shire, and an educational grant from Banner.

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Dellon, E. Management of refractory eosinophilic oesophagitis. Nat Rev Gastroenterol Hepatol 14, 479–490 (2017). https://doi.org/10.1038/nrgastro.2017.56

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