Joy Chang, MD, MS

Panelists discuss how access challenges include insurance barriers and prior authorizations for medications, while identifying key gaps in eosinophilic esophagitis (EoE) care such as the need for biomarkers, better food trigger identification tests, severity progression understanding, and comparative treatment studies. They also highlight emerging therapies such as new topical steroids, biologics targeting T2 inflammation, transnasal endoscopy, and esophageal string tests that promise to make monitoring and treatment more accessible and less burdensome than the disease itself.

Panelists discuss how esophageal dilation is an important therapeutic intervention for the fibrostenotic complications of eosinophilic esophagitis (EoE). They emphasize the need to treat inflammation first before dilation, using techniques such as balloon pull-through or Savary dilators depending on stricture location and severity, and the importance of achieving controlled mucosal disruption while being less aggressive than with peptic strictures to ensure safety and effectiveness.

Panelists discuss how dietary elimination therapy for eosinophilic esophagitis (EoE) involves empirically removing common food triggers (dairy, wheat, eggs, soy, seafood, nuts), with less restrictive approaches such as eliminating 1 to 2 foods being more feasible than the traditional 6-food elimination. The panelists emphasize the critical role of dieticians, avoiding combination therapies when possible, and allowing flexibility with “diet holidays” while monitoring for symptom recurrence.

Panelists discuss how monitoring eosinophilic esophagitis (EoE) involves short-term endoscopic evaluation at 2 to 6 months to assess symptom, histologic, and endoscopic response to treatment. This is followed by annual long-term follow-up visits to monitor adherence, address obstacles, and watch for adverse effects. They emphasize the chronic nature of the disease because EoE returns when treatment is discontinued.

Panelists discuss how dupilumab serves as a step-up therapy for patients for whom first-line treatments (proton pump inhibitors [PPIs], topical steroids, or dietary therapy) fail, with particular advantages for patients with multiple atopic conditions as it can treat eosinophilic esophagitis along with asthma, eczema, or food allergies simultaneously. Pediatric treatment decisions focus on 3 key goals: symptom resolution and growth, ensuring treatment is not worse than the disease, and improving tissue appearance.

Panelists discuss how budesonide oral suspension demonstrates a favorable safety profile with transient adverse events similar to placebo rates and minimal risk of adrenal suppression when used alone. It has the advantage of being FDA-approved specifically for esophageal delivery rather than repurposing lung medications, which eliminates variability in homemade formulations and ensures consistent drug delivery to the esophagus.

Panelists discuss how budesonide oral suspension was developed as a palatable, easy-to-use topical steroid that coats the esophagus like a lotion and demonstrated strong clinical efficacy in the largest US eosinophilic esophagitis (EoE) trial, with 62% of patients achieving histological response and 53% achieving symptom improvement, including 30% achieving both outcomes compared with 0% with placebo.

Panelists discuss how first-line eosinophilic esophagitis (EoE) treatment involves shared decision-making between proton pump inhibitors, topical swallowed steroids, or food elimination diets, with therapy selection based on patient preferences, lifestyle factors, developmental stage in children, and the understanding that treatment approaches can evolve over time as circumstances change.

Panelists discuss how proper eosinophilic esophagitis (EoE) diagnosis requires at least 6 biopsies from 2 esophageal levels due to the patchy nature of the disease, and how severity assessment using tools such as the AGA IC score incorporates symptoms, endoscopic findings, and histologic features to guide treatment decisions and potentially prevent progression to fibrosis and structuring through earlier intervention.

Panelists discuss how eosinophilic esophagitis (EoE) diagnosis requires both clinical symptoms and histologic confirmation through upper endoscopy with biopsies showing 15 or more eosinophils per high-power field, while identifying key endoscopic features such as edema, rings, exudates, furrows, and strictures, though diagnostic challenges include biopsy variability and parental recognition of symptoms in pediatric cases.

Panelists discuss how distinguishing eosinophilic esophagitis (EoE) from other conditions such as gastroesophageal reflux disease requires careful clinical context evaluation. They note that not all esophageal eosinophilia above 15 per high-power field indicates EoE and emphasize the importance of considering patient history, endoscopic findings, symptom patterns, and potential comorbid conditions such as hypereosinophilic syndrome, celiac disease, or achalasia.

Panelists discuss how inflammation in eosinophilic esophagitis (EoE) correlates with symptoms and long-term complications such as strictures, while emphasizing the importance of screening patients with other atopic conditions such as eczema, asthma, and food allergies for potential EoE given the shared type 2 inflammatory process.

Panelists discuss how eosinophilic esophagitis (EoE) presents with dysphagia and adaptive eating behaviors in adults and feeding difficulties in children and has increasing prevalence rates potentially driven by environmental factors and early life exposures rather than just improved awareness.

Chang explains the importance of collaboration between gastroenterologists and allergists in EoE care and praises recent ACG guidelines on disease management.

Chang reviews key points from her recent paper on the evolving landscape of eosinophilic esophagitis management and lingering knowledge gaps.