• יו"ר: ד"ר אורי סגול
  • מזכירה: ד"ר פביאנה בנימינוב
  • חברי ועד: ד"ר אמאני בשארה, ד"ר גיל בן יעקב, ד"ר דוד ירדני, ד"ר דורון בולטין, פרופ' מחמוד מחמיד
סקירה

Eosinophilic Esophagitis - The Light at the End of the Tunnel

Novel Monotherapy and Maintenance Treatment - The Keys to Achieving Remission and Preventing Complications in Eosinophilic Esophagitis

AUTHOR: Edoardo Vincenzo Savarino, University of Padua, Padua, Italy

 Eosinophilic Esophagitis (EoE) is a chronic immune-mediated disorder of the esophagus characterized by eosinophilic predominant inflammation [1]. Its prevalence and incidence increased dramatically in the last two decades, and it has been recently estimated that the pooled EoE prevalence is 34 cases per 100,000 persons (95% CI: 22.3–49.2) among children and 42.2 cases per 100,000 persons (95% CI:31.1–55) among adults [2]. These numbers underline the relevance of the disease and the need for early recognition and treating correctly.

I personally have had more than 15 years of experience in treating EoE. My first patient with EoE was my cousin in 2008, who was diagnosed after an episode of bolus impaction requiring endoscopic bolus removal, done by me. Since then, I have run a referral centre for EoE patients with complex needs in Padua, with more than 1000 patients with EoE currently followed at our Institution. I have participated in many therapeutic trials during the past 15 years and I know the difficulties we are facing in identifying a valuable drug for treating EoE. Indeed, until recently, we had to treat our patients through different approaches: diet, limited by their variety, complexity and poor adherence (elemental diet, allergic-testing driven diet, 2-4-6 food elimination diet); proton pump inhibitors (PPIs), limited by their intrinsic mechanism of action which make them symptomatically effective in approximately 50% of patients; and various formulations of topical corticosteroids, mostly adapted from asthma therapeutic armamentarium, limited by their mode of administration (inability to reach the esophageal mucosa) [3]. Moreover, the available data are unclear on the ability of these therapeutic approaches of being effective in the long-term at preventing complications like esophageal strictures and esophageal remodeling. Finally, no adequate comparative trials are available to help guide patients and doctors on correct positioning of these options.

Only in 2019, a randomized placebo-controlled study by Lucendo et al. identified the relevance of a dedicated, EoE-specific formulation of topical corticosteroid Budesonide Orodispersible Tablets (Jorveza), in determining the rates of clinical, endoscopic and histological remission [4]. Jorveza is currently our treatment of choice in patients in whom PPIs or diet are not effective or for those with severe symptoms or with high-degree of esophageal inflammation or already established stricture. Since we have had access to this drug in the past year, we have witnessed incredible results in terms of symptom remission, ability to eat, social functioning, improvement of quality of life and a marked reduction in stricture development, endoscopic dilatation and hospitalization. Recently, we analyzed the available data in medical literature in an attempt to statistically compare current therapeutic approaches for treating EoE, observing that Jorveza ranked first among the drugs, in terms of efficacy in all the domains usually evaluated for EoE management: symptom control, endoscopic remission, histologic normalization and improvement in quality of life [5]. These data parallel what we have seen in clinical practice in the last year, and corroborate our approach and use of Jorveza in clinical practice. Unfortunately, the drug is not available everywhere, but I strongly hope that Jorveza will be available to every patient in the next one or two years.

Another point of discussion is related to the need of maintenance treatment in EoE. All the recent data from RCTs and cohort studies emphasize the very high recurrence rate after cessation of therapy (approximately 50% at 3 months and 75% at 6 months) [6]. Moreover, an increasing body of knowledge confirms that suspension of therapy is associated with more hospitalizations, strictures and need of dilatation [7]. Accordingly, I strongly recommend to my patients maintenance treatment, either with PPI or topical steroid at the lowest effective dose, for patients who respond to induction treatment. In particular, topical steroids have a good safety profile for induction and maintenance of remission in the short-medium term, supporting their role as effective and safe maintenance therapy. Nevertheless, more data are necessary to further corroborate our therapeutic approach in the long-term. Moreover, we eagerly await the availability of topical corticosteroid formulations that are suitable for our pediatric patients with EoE.

References:

1. Dellon ES, Gonsalves N, Abonia JP, Alexander JA, Arva NC, Atkins D, et al. International consensus recommendations for eosinophilic gastrointestinal disease nomenclature. Clin Gastroenterol Hepatol. 2022;20(11):2474–2484.e3.

2. Navarro P, Arias Á, Arias-González L, Laserna-Mendieta EJ, Ruiz-Ponce M, Lucendo AJ. Systematic review with meta- analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther. 2019;49(9):1116–25.

3. Visaggi P, Ghisa M, Barberio B, Maniero D, Greco E, Savarino V, Black CJ, Ford AC, de Bortoli N, Savarino E. Treatment trends for eosinophilic esophagitis and the other eosinophilic gastrointestinal diseases: Systematic review of clinical trials. Dig Liver Dis. 2023 Feb;55(2):208-222.

4. Lucendo AJ, Miehlke S, Schlag C, et al. Efficacy of budesonide orodispersible tablets as induction therapy for eosinophilic esophagitis in a randomized placebo-controlled trial. Gastroenterology 2019; 157: 74-86.

5. Visaggi P, Barberio B, Del Corso G, de Bortoli N, Black CJ, Ford AC, Savarino E. Comparison of drugs for active eosinophilic oesophagitis: systematic review and network meta-analysis. Gut. 2023 Nov;72(11):2019-2030.

6. Straumann A, Lucendo AJ, Miehlke S, Vieth M, Schlag C, Biedermann L, et al. for the International EOS-2 Study Group. Budesonide orodispersible tablets maintain remission in a randomized, placebo-controlled trial of patients with eosinophilic esophagitis. Gastroenterology 2020 Nov;159(5):1672-1685.e5.

7. Schupack DA, Ravi K, Geno DM, Pierce K, Mara K, Katzka DA, Alexander JA. Effect of maintenance therapy for eosinophilic esophagitis on need for recurrent dilation. Dig Dis Sci 2021;66(2):503–10.

 

נושאים קשורים:  סקירה