Eosinophilic Esophagitis is Rarely Severe in Adolescents or Adults, Study Finds

Most patients with eosinophilic esophagitis (EoE) exhibit mild or moderate disease severity, with duration between first symptom and index date, as well as number of current treatment lines, increasing with worsening severity, according to a recent retrospective cohort study.¹

The last 30 years have seen a dramatic increase in the EoE knowledge base, establishing it as a well-characterized, familiar disease. Diagnostic guidelines have been published, pathogenesis is being investigated, and descriptive epidemiology – including an increasing incidence and prevalence – has been reported. However, very little information exists regarding the comparative severity of the disease.²

“This information could improve understanding of EoE disease features and consequently inform management strategies in EoE,” wrote Evan Dellon, MD, MPH, division of gastroenterology and hepatology, department of medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, and colleagues. “Here, we aim to assess the distribution of physician-assessed and an adapted I-SEE-assessed EoE disease severity among patients with EoE in the USA and identify any correlation between EoE disease severity and physician/patient characteristics or treatment patterns.”¹

Dellon and colleagues recruited clinicians from a US nationwide panel of physicians; they completed a custom-designed electronic case report form (eCRF) for their patients with histologically confirmed EoE diagnoses between December 2021 and January 2022. Charts were included if patients had a histologically confirmed diagnosis within the last 10 years, were ≥11 years old at index, and had medical records for ≥6 months and for ≥1 EoE-related physician visit after index. Patients were excluded if they had gastric or esophageal neoplasms, human immunodeficiency virus, or other life-threatening conditions during baseline.¹

EoE severity was classified by clinical severity – symptoms, histopathology, endoscopy, and EoE-related HCRU – and markers of severity – treatment failure and presence of coping or adaptive behaviors. The utilized data elements were conclusions from histology or pathology reports, high-power microscopy peak eosinophil count, non-EoE-related comorbidities, number and frequency of esophageal dilations, history of treatment failure with PPIs and topical corticosteroids, among other factors.¹

A total of 126 gastroenterologists and 60 allergists/immunologists contributed 411 charts. Investigators determined that 399 met the eligibility criteria, which included 74 adolescents and 325 adults, with mean (Standard Deviation [SD]) ages of 14.9 (1.8) and 32.9 (11) years, respectively. Most patients had at least 1 comorbidity; the most frequently reported among adolescents and adults were allergic rhinitis (50% and 31.7% respectively) and asthma (41.9% and 33.8% respectively). Allergic rhinitis prevalence and food allergy also increased significantly with EoE severity in adults (P <.05).¹

Investigators noted an increase in mean (SD) duration from first EoE symptom to index date with increasing EoE disease severity (P <.001). When it was first documented, reports of food impactions in adolescents and of dysphagia, food impactions, vomiting, and regurgitation in adults increased significantly with increasing disease severity (all, P <.01). At index, dysphagia and food impaction reports numerically increased with EoE severity in adolescents; food impactions, regurgitation, and weight loss at index significantly increased with EoE severity in adults (all, P <.01).¹

Because no US Food and Drug Administration-approved medications were available during this study, the most frequently used treatments following the index date, regardless of severity, were PPIs as first-line treatment (adolescents: 79.7%; adults: 74.2%) and topical corticosteroids as both second-line (adolescents 39.5%; adults: 49.4%) and third-line treatment (adolescents: 36.4%; adults: 23.1%).¹

Ultimately, investigators determined roughly 90% of patients with EoE had mild or moderate disease. A greater number of treatment lines were taken by patients with moderate or severe disease, attributed to previous treatment failure or discontinuation.¹

“This may suggest that initial treatment should be tailored to perceived EoE disease severity and that improving our understanding of the real-world severity distribution of EoE, as well as treatment responses following different therapies for each EoE disease severity class, has the potential to help guide management strategies,” Dellon and colleagues wrote.¹

References

1. Dellon ES, Furuta GT, Feuerstadt P, et al. Assessment of real-world disease severity in patients with eosinophilic esophagitis in the United States. Therapeutic Advances in Gastroenterology. 2025;18. doi:10.1177/17562848251347361

2. Dellon ES, Khoury P, Muir AB, et al. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology. 2022;163(1):59-76. doi:10.1053/j.gastro.2022.03.025