Epidemiologic Burden and Projections for Eosinophilic Esophagitis-Associated Emergency Department Visits in the United States: 2009-2030

Insights into the natural history and disease course of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease marked by eosinophilic inflammation and esophageal dysfunction, with a significant impact on morbidity, quality of life, and health care utilization. Once considered rare, EoE has become increasingly prevalent, with global estimates exceeding 140 cases per 100,000 individuals. This rise highlights the need to better understand the natural history and disease course to inform diagnosis and management strategies. Evidence suggests that EoE is a progressive condition, such that untreated inflammation contributes to esophageal remodeling and fibrotic complications over years to decades. Patients can develop esophageal food impactions, leading to emergency department utilization and the need for emergent endoscopy. In addition, patients with fibrostenotic disease can require serial dilations. Long-term management, including dietary therapy, proton pump inhibitors, topical corticosteroids, and newer therapies such as dupilumab, demonstrate promise in altering the disease course. However, variability exists in the strength of evidence regarding each therapy's ability to halt or reverse fibrosis. Knowledge gaps persist, particularly in defining fibrosis, identifying phenotypes prone to progression, and tailoring therapies to individual patients. Addressing these gaps will require continued research into understanding fibrosis progression and how therapies alter this trajectory. These efforts are poised to significantly improve clinical care and enhance outcomes for patients with EoE.

Factors associated with treatment response in eosinophilic esophagitis patients: Experience from a pediatric tertiary care center

Background: Eosinophilic esophagitis (EoE) is a disease characterized by eosinophilic inflammation of the esophagus and associated esophageal dysfunction with increasing worldwide prevalence. Clinical presentation is nonspecific and varies with age, with limited studies in the pediatric population. Objective: Our study aimed to compile clinical phenotypes, esophagogastroduodenoscopy findings, and treatment response of EoE in a tertiary pediatric center, and to examine factors associated with the response of treatment. Methods: In this retrospective study, we reviewed the medical records of 824 patients diagnosed with EoE at Children's Hospital of Michigan from 2011 to 2021. Data collected included a demographic profile, symptoms, esophagogastroduodenoscopic and histopathologic findings, treatment modalities, response, and compliance. We then performed a multivariable logistic regression to assess the associating factors that influenced the treatment response rate. Results: A high proportion of males and coexisting allergic conditions were observed in the patients with EoE, with the most common presentation of vomiting in children and of abdominal pain in adolescents. Among 656 of the 824 patients who had follow-up esophagogastroduodenoscopy, treatment response rates varied among modalities, with proton-pump inhibitor treatment exhibiting the highest response rate, at 60.8%, followed by diet modification (50%) and topical steroid treatment (43.5%). Significant predictors of normal endoscopic findings at follow-up included female gender, normal endoscopic appearance, good compliance to treatment, and absence of topical steroids in the treatment regimen. There were no significant differences in outcomes observed for targeted elimination led by a skin-prick test or specific immunoglobulin E test. Medication compliance did not significantly differ among the treatment options. Conclusion: Managing EoE in pediatric patients poses significant challenges, which emphasizes the need for multidisciplinary care to achieve treatment response effectively. The findings underscore the complexity of managing EoE and the need for individualized treatment approaches. Further research is warranted to elucidate the underlying mechanisms and optimize management strategies for pediatric patients with EoE.

Diagnosing eosinophilic esophagitis in pediatric patients

INTRODUCTION

Eosinophilic esophagitis (EoE) is an increasingly common disease that can present in children with the symptoms of feeding dysfunction, abdominal pain, vomiting, reflux-like symptoms, dysphagia, or food impaction. Diagnostically, children must have symptoms, dense esophageal eosinophilia, and other potential causes of these findings ruled out. Diagnostic recognition is critical to avoid food impactions and potential esophageal stricture development.

AREAS COVERED

In this review, a PubMed search using the search terms eosinophilic esophagitis, pediatric, and diagnosis were used to cover the last 10 years (2013-2023) of literature.

EXPERT OPINION

Early detection of EoE in children depends on increased recognition of diagnostic clues by many specialties. As increasing efforts to publicize the importance of EoE in children continues, our understanding of the molecular underpinnings of EoE is making rapid advances. Increasing growth of this knowledge base will provide more personalized diagnostic approaches, targeted interventions, and innovative treatments.

Cost-Effectiveness Analysis of Current Treatment Options for Eosinophilic Esophagitis

INTRODUCTION

The management strategies for eosinophilic esophagitis include proton pump inhibitors (PPIs), swallowed topical corticosteroids (tCSs), elimination diets, and the biologic agent dupilumab, although there remains little guidance on the selection of initial treatment. We performed cost-effectiveness analyses to compare these approaches of first-line therapy.

METHODS

A Markov model was constructed from a payer perspective to evaluate the cost-effectiveness of first-line therapies for eosinophilic esophagitis, including PPI, tCS, and 6-food elimination diet (SFED), with crossover in treatments for primary and secondary nonresponse. The primary outcome was incremental cost-effectiveness ratio at 2 and 5-year time horizons. Secondary analyses included modeling from a societal perspective that also accounted for patient-specific costs, as well as a separate simplified model comparing dupilumab with tCS and PPI.

RESULTS

In the base-case scenario (5-year time horizon), the average costs were SFED: $15,296.81, PPI: $16,153.77, and tCS: $20,975.33 as initial therapy, with SFED being the dominant strategy (more effective/less costly), while PPI offered the lowest cost on a 2-year time horizon. From a societal perspective, PPI was the dominant initial strategy on both 2 and 5-year time horizons. Among pharmacologic therapies, PPI was the most cost-effective first-line option. Dupilumab was not cost-effective relative to tCS, unless the quarterly cost is reduced from $7,311 to $2,038.50 per price threshold analysis under permissive modeling conditions.

DISCUSSION

SFED was the most effective/least costly first-line therapy from the payer perspective while PPI was more cost-effective from the societal perspective. PPI is also the most cost-effective pharmacologic strategy. Dupilumab requires substantial cost reductions to be considered cost-effective first-line pharmacotherapy.

Perinatal Environmental Risks for Eosinophilic Esophagitis: A Systemic Review and Meta-Analysis

There are limited data on the association of eosinophilic esophagitis (EoE) and environmental risk factors. The aim of this study was to determine the potential associations between perinatal risk factors and EoE. A search was conducted for relevant studies published up to December 12th, 2023, using MEDLINE, EMBASE, Scopus, Web of Sciences, and Cochrane databases. Risk ratios with the 95% confidence interval (CI) were estimated using a random-effects model. Case-control or cohort studies that determined perinatal environmental factors within the first year of life and their association with EoE were included. Six case-control studies were included in the analysis. Six studies (2,087 EoE and 6,786 controls) were included for risk of infant antibiotic use with a pooled risk ratio of 1.30 (95%CI: 1.11-1.52, I2 = 76%), and five studies were included for cesarean section with a pooled risk ratio of 1.22 (95%CI: 1.10-1.34, I2 = 5%). There were three studies for breastfeeding with a pooled risk ratio of 1.07 (95%CI: 1.00-1.15, I2 = 0%); five studies were included for preterm birth with a pooled risk ratio of 1.52 (95%CI: 1.14-2.04, I2 = 48%). There were three studies for neonatal intensive care unit admission with a pooled risk ratio of 1.75 (95% CI: 1.41-2.18, I2 = 0%). Publication bias was found between EoE and infant antibiotic use and cesarean section, but not for EoE and preterm birth, neonatal care unit admission, or breastfeeding. This meta-analysis suggests a weak association between antibiotic use during the first year of life, cesarean section, preterm birth, and neonatal intensive care unit admission and a possible risk of EoE. Further studies are warranted to confirm these findings as they may be indirect associations rather than causal.

Epidemiology and Racial Differences of EoE Patients in a U.S. Veterans Population

BACKGROUND

Eosinophilic esophagitis (EoE) is increasing in prevalence but there is a lack of population-based studies. We sought to determine the prevalence, demographics, and associated atopic diseases in the Veterans Affairs (VA) population.

METHODS

A nationwide analysis of data from the VA patient population was done using a Veterans Health Administration database. EoE was identified using ICD9 (530.13) and ICD10 (K20.0) codes from October 2008 to June 2020. Demographic data, smoking status, BMI, treatment, and ICD codes for atopic diagnoses were collected. Two sample proportion z-tests, Chi-square tests, two-sample t tests, and one-way ANOVA were used to assess associations across demographic categories.

RESULTS

We identified a total of 11,775 patients with an EoE diagnosis: 91% male, 83% White, 8.6% Black, and 5% were of Hispanic ethnicity. The prevalence of EoE increased over time. At diagnosis, the mean age was 48.5 years overall, 51.6 years for Black patients, 45.3 years for Hispanic patients, and 48.2 years for Whites. Dysphagia was the most common symptom overall, but a higher percentage of Blacks and females were found to report chest pain (p < 0.0001, h = 0.32). With the exception of urticaria and atopic dermatitis, both Blacks and Hispanics had a higher incidence of atopic conditions compared to other races and ethnicities (p < 0.0001).

CONCLUSION

While EoE is seen primarily in White males, our study shows that a notable percentage of patients were Black or Hispanic, suggesting that EoE should be considered in non-white patients. The later age of diagnosis in this group could represent a lack of awareness about EoE among non-white patients. More research is needed to study these associations.

Eosinophilic esophagitis in the era of biologics

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic inflammatory, disabling disorder characterized by prominent eosinophilic inflammation of the esophagus, leading to troublesome symptoms including dysphagia and food impaction. The natural history of EoE is poorly known, but it may lead to esophageal strictures. The therapeutic armamentarium is expected to grow in the near future, especially due to the availability of novel biological therapies targeting crucial inflammatory pathways of EoE.

AREAS COVERED

In this review, we discuss the main clinical features and natural history of EoE, focusing on the current therapeutic strategies, as well as past and current trials investigating biologics for its treatment.

EXPERT OPINION

Dupilumab has been the first approved biologic drug for the treatment of EoE; long-term studies assessing how it could change the natural history of EoE are awaited. Novel biological drugs or other molecules are currently under study and could change the current treatment algorithms in the near future. Proper drug positioning and long term 'exit strategies' are yet to be defined.

Associations of Eosinophilic Gastrointestinal Disorders with Other Gastrointestinal and Allergic Diseases

Eosinophilic gastrointestinal disorders (EGIDs) are becoming more common causing significant suffering and reduced quality of life. These conditions can affect different parts of the digestive system, either individually or in combination. Recognition of their link to allergic disorders or other gastrointestinal (GI) diseases has raised questions about their shared underlying mechanisms, which has had implications for diagnosis and management. The authors critically examine the current understanding of the connection between EGIDs and allergic conditions (ie, atopic dermatitis, allergic rhinitis, asthma, and food allergy) and GI diseases (ie, inflammatory bowel disease, celiac disease, gastroesophageal reflux disease, and motility disorders).

Epidemiologic and Clinical Clues to the Etiology of Eosinophilic Esophagitis

Despite the rising prevalence and incidence of eosinophilic esophagitis (EoE), the etiology and pathophysiology remain unknown. Studies to date suggest that complex interactions between genetic and environmental risk factors result in the development and presentation of disease. Examining environmental factors both in the early life and later life exposures offers potential clues for the development of EoE, although challenges exist in making causal inferences due to diagnostic delay and access, ascertainment biases, and misclassification of cases. The authors review studies supporting early life factors as etiologic factors in the development of EoE.

Long-term course of untreated asymptomatic esophageal eosinophilia and minimally symptomatic eosinophilic esophagitis

Background and study aims The long-term course of untreated asymptomatic esophageal eosinophilia (aEE) and minimally symptomatic eosinophilic esophagitis (mEoE) are not well understood. This study aimed to clarify this course. Patients and methods A total of 36 patients with EE who were endoscopically followed up for more than 5 years, and who underwent more than one endoscopy evaluation after the first diagnosis, were investigated. These patients were divided into two groups according to the presence or absence of the continuous treatment: no treatment group (NT group, n=22) and proton pump inhibitor/potassium competitive acid blocker group (Tx group, n=14). Symptoms and endoscopic and histological findings were retrospectively reviewed according to endoscopic phenotypes. Endoscopic assessment was performed using the EoE endoscopic reference score (EREFS). Results The median follow-up period was 84.5 months in the Tx group and 92 months in the NT group. During the follow-up period, about half of the patients in the Tx-diffuse group persisted EREFS >3, while the remaining half had EREFS ≤2. The total EREFS in the NT-diffuse group remained almost unchanged (median: 2-4) without apparent exacerbation. In contrast, EREFS in the NT-localized group exhibited an unchanged or gradually decreasing trend, with statistical significance from the first diagnosis to 72 to 83 months after. Conclusions Untreated aEE and mEoE are not likely to worsen even without treatment at least for a median follow-up of 7 years. Instead, the localized type may spontaneously improve, implying a different pathogenesis in the presence of the diffuse type. Further studies should clarify the long-term prognosis.