Evan Dellon, MD, MPH, is a professor in the division of gastroenterology and hepatology and director of the Center for Esophageal Diseases and Swallowing at UNC School of Medicine.

Evan Dellon, MD, MPH

Solidifying Dupilumab’s Role in Eosinophilic Esophagitis Care, With Evan Dellon, MD, MPH

American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting

 are solidifying dupilumab (Dupixent)’s role in eosinophilic esophagitis (EoE) care, spotlighting sustained reductions in dysphagia and odynophagia as well as endoscopic features of the disease.

Findings from the post-hoc analysis of LIBERTY EoE TREET and the pooled analysis of LIBERTY EoE TREET and EoE KIDS were presented by Evan Dellon, MD, MPH, a professor of medicine and adjunct professor of epidemiology at the University of North Carolina School of Medicine in Chapel Hill.

Dysphagia and Odynophagia in LIBERTY EoE TREET

LIBERTY EoE TREET data were pooled from patients ≥12 years of age treated with dupilumab qw or placebo for 24 weeks in Parts A and B of the trial who continued to Part C and received dupilumab qw to week 52. The number of days without dysphagia and number of days without odynophagia over a 14-day period were analyzed at baseline and every 2 weeks to week 52. The proportion of patients with 0 days of dysphagia or 0 days of odynophagia over each 14-day period was also analyzed.

At baseline, all patients reported dysphagia and 95% and 88% of patients who received dupilumab and placebo, respectively, reported odynophagia. At week 24, the mean number of days without dysphagia was greater in patients on dupilumab than placebo (8.7; 95% CI, 7.8-9.5 vs 5.5; 95% CI, 4.2-6.7; 

<.0001). The mean number of days without odynophagia was also greater in patients on dupilumab versus placebo (10.1; 95% CI, 9.3-10.8 vs 6.8; 95% CI, 5.5-8.1; 

“Over the 24 weeks, compared to placebo, the number of dysphagia free days significantly increased with the dupilumab treatment, and that's a concept that I think is easy to convey to patients,” Dellon explained to 

At week 52, the mean number of days without dysphagia and without odynophagia increased in patients switching from placebo to dupilumab (dysphagia 8.6; 95% CI, 7.2-10.0 and odynophagia 8.9; 95% CI, 7.4-10.4) and was maintained in patients continuing dupilumab (9.4; 95% CI, 8.4-10.4 and 10.6; 95% CI, 9.9-11.4). At week 24, greater proportions of dupilumab-treated patients had 0 days of dysphagia and 0 days of odynophagia over a 14-day period.

Endoscopic EoE Improvements in LIBERTY EoE TREET and EoE KIDS

The analysis included patients from Part A of EoE KIDS randomized to weight-tiered, higher-exposure dupilumab or placebo for 16 weeks, and patients from Parts A/B of LIBERTY EoE TREET randomized to weekly dupilumab 300 mg or placebo for 24 weeks.

Endoscopic Reference Score (EREFS) measuring the severity of edema, rings, exudates, furrows, and strictures was based on the worst observed region calculated using the highest score for each feature from either the proximal or distal esophagus. EREFS total and individual feature scores, and the proportion of patients with scores of 0 in each feature were assessed at baseline and week 16 or 24 based on the end of each study’s double-blind treatment period.

“This was looking at endoscopic findings and endoscopic severity, particularly as measured by the EREFS, and that's actually something in the guidelines that's been emphasized, where everybody who's doing an endoscopy for suspected EoE or for known EoE that you're following, you really should be calculating the score,” Dellon said.

In the total pooled cohort, 159 patients received dupilumab and 152 received placebo. Investigators noted baseline characteristics were generally comparable between the groups.

At weeks 16 and 24, results showed EREFS total score was reduced with dupilumab versus placebo (1.5; 95% CI, 1.3-1.8 vs 3.9; 95% CI, 3.6-4.2; 

<.0001), as were scores for each feature. The proportion of patients scoring 0 for a given feature increased with dupilumab treatment:

Editors’ note: Dellon reports disclosures with AbbVie, Alfasigma, Amgen, AstraZeneca, Ferring, GSK, Phathom, Regeneron Pharmaceuticals, Sanofi, Shire/Takeda,Target RWE, and others.

Dellon ES, Gupta M, Chehade M, et al. Sustained Treatment Response With Dupilumab in Dysphagia and Odynophagia in Adults and Adolescents With Eosinophilic Esophagitis: Post-Hoc Analysis of the LIBERTY EoE TREET Study up to 52 Weeks. Presented at the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting. Phoenix, Arizona. October 27-29, 2025.

Dellon ES, Chehade M, Gonsalves NP, et al. Dupilumab Improves Endoscopic Features of Eosinophilic Esophagitis (Edema, Rings, Exudates, Furrows, and Strictures): Pooled Analysis from 2 Phase 3 Studies (EoE KIDS and LIBERTY EoE TREET). Presented at the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting. Phoenix, Arizona. October 27-29, 2025.

Videos

Dellon reviews data from a post-hoc analysis of dysphagia and odynophagia in LIBERTY EoE TREET and a pooled analysis of endoscopic improvement in 2 trials.

Improving Access and Addressing Gaps in Guidelines and Emerging Therapies

Access challenges for EoE therapies encompass practical patient considerations and systemic barriers. Patient-level obstacles include tolerability concerns such as injection anxiety with biologics, adherence difficulties with twice-daily medications, and family dynamics around dietary restrictions that can create household discord. Systemic barriers involve insurance coverage variability, prior authorization requirements, and complex approval processes that differ significantly between insurers. Provider advocacy and persistence become crucial in navigating these challenges, requiring education about available resources and sustained effort to secure appropriate treatments for patients.

Significant knowledge gaps persist in this relatively young disease entity, with many practicing physicians lacking formal EoE education. Research priorities include developing biomarkers for disease monitoring, creating reliable tests to predict food triggers for dietary therapy, understanding disease severity progression patterns, and determining optimal treatment sequencing. The field needs comparative effectiveness studies between available therapies and personalized treatment approaches based on individual disease characteristics. Only 2 FDA-approved medications exist, both approved within the last 3 to 4 years, highlighting the nascent state of evidence-based treatment options.

Emerging therapeutic developments offer promising advances in multiple domains. New topical steroid formulations such as effervescent and fluticasone preparations aim to improve drug delivery to the esophagus. Additional biologics targeting type 2 inflammatory pathways, including benralizumab, and small molecule inhibitors such as TSLP inhibitors are in development. Beyond pharmacological advances, innovative monitoring approaches include transnasal endoscopy for unsedated procedures, particularly beneficial in pediatric populations, and esophageal string tests that could reduce reliance on full endoscopic evaluations. The field emphasizes developing monitoring strategies that are less burdensome than the disease itself. This exciting therapeutic landscape requires maintaining close patient relationships to capitalize on emerging options, while fostering clinician-patient partnerships that are essential for managing this chronic condition requiring long-term treatment adherence and lifestyle modifications.

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.

Utility of Esophageal Dilatation in EoE

Esophageal dilation addresses the fibrostenotic component of EoE, which results from longstanding inflammation leading to scarring, rings, and strictures that cannot be resolved through anti-inflammatory treatments alone. This mechanical intervention becomes necessary when structural narrowing causes persistent dysphagia despite adequate inflammatory control. Clinicians maintain a low threshold for dilation in patients with ongoing swallowing difficulties, as subtle strictures can be easily missed during routine endoscopy.

Technical approaches include balloon dilation and wire-guided bougie techniques, with selection based on stricture characteristics. Focal distal strictures may be treated with through-the-scope balloons, while multifocal narrowings throughout the esophageal length may benefit from Savary dilators that provide both radial and longitudinal shearing forces. The balloon pull-through technique allows comprehensive evaluation of the entire esophageal caliber while enabling targeted treatment of identified narrowed areas. Practitioners emphasize achieving visible mucosal disruption or “dilation effect” as evidence of therapeutic intervention, though this requires careful patient communication using appropriate terminology.

Safety considerations and technique refinements distinguish EoE dilation from peptic stricture treatment. EoE tissue tends to tear more readily, necessitating gradual, conservative approaches rather than aggressive dilation. Optimal timing involves treating inflammatory disease first, as dilating inflamed tissue increases postprocedural discomfort and complications. Pediatric applications require additional considerations, including family education and diagnostic aids such as esophagrams or EndoFLIP technology to identify subtle strictures not apparent on visual inspection. These tools help detect narrowings present in up to half of cases where visual assessment appears normal, enabling informed discussions with families about intervention necessity. The procedure is routinely performed during adult endoscopy but requires more deliberate planning in pediatric populations, emphasizing the importance of comprehensive esophageal evaluation before biopsy collection to identify all areas requiring therapeutic intervention.

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.

Dietary Elimination Approaches in EoE

Dietary elimination therapy represents a nonpharmacological treatment option that appeals to patients seeking natural approaches to managing EoE. The traditional 6-food elimination diet removes the most common EoE triggers: dairy (animal milk), wheat, eggs, soy, seafood (shellfish and fin fish), and tree nuts. However, recent approaches favor less restrictive strategies, starting with elimination of the most common triggers (dairy alone or dairy plus wheat) before progressing to more comprehensive restrictions, as data suggest single-food elimination can be as effective as 4-food elimination diets.

The empirical elimination process involves removing suspected trigger foods, followed by endoscopic evaluation to assess disease remission, then systematic food reintroduction to identify specific individual triggers. This approach requires significant patient motivation and adherence, as it demands careful attention to food labels, hidden ingredients, and meal planning. Dietitian involvement is crucial from the beginning, providing expertise in label reading, identifying hidden food sources, and guiding both elimination and reintroduction phases that gastroenterologists may lack.

Implementation considerations vary significantly by patient demographics and life circumstances. Younger children may benefit from family-controlled environments that facilitate dietary adherence, whereas adolescents face social challenges with peer dining and activities that complicate restrictive diets. University-aged patients often struggle with meal preparation independence, making dietary therapy less feasible. Combination therapy with medications is generally discouraged due to adherence challenges, though proton pump inhibitors may be continued for concurrent reflux disease. Flexibility strategies, including “diet holidays” for special occasions, can improve long-term sustainability in adult populations, though this approach may confuse younger children regarding dietary consistency. The ultimate goal involves identifying specific individual triggers rather than the permanent elimination of all 6 food categories, making long-term management more feasible while maintaining effective disease control without medications.

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.

Evan Dellon, MD, MPH

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