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

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.

Videos

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.

Monitoring Approaches for Different Treatments for EoE

Treatment monitoring for EoE employs a systematic approach evaluating 3 primary domains: symptomatic improvement, histological response through esophageal biopsies, and endoscopic appearance changes. The timing of initial response assessment varies by treatment modality, with proton pump inhibitors evaluated at 8 weeks, topical corticosteroids at 2 to 3 months, dupilumab at 4 to 6 months, and food elimination diets assessed every 6 to 8 weeks for each eliminated food category. These evaluations determine whether patients achieve remission or require treatment modifications.

Monitoring must distinguish between inflammatory and fibrostenotic disease components, as current therapies target inflammation but cannot reverse established scarring. Endoscopic assessment focuses on inflammatory features including edema, furrows, and exudates, which respond to medical therapy, whereas fibrostenotic changes may require mechanical interventions such as dilation. The evaluation process determines whether patients are responders in remission or need alternative therapeutic approaches.

Long-term management emphasizes annual clinical follow-up to maintain treatment adherence and monitor for complications. These visits provide opportunities to discuss emerging therapies, assess medication adherence, address insurance obstacles, and evaluate ongoing symptoms that might indicate a need for treatment optimization. Regular monitoring becomes particularly important given the chronic nature of EoE and the tendency for patients to discontinue therapy once symptoms improve, leading to disease recurrence. Long-term considerations include monitoring for treatment-related adverse effects, especially with newer biologic therapies where immune system targeting may potentially shift inflammatory patterns or contribute to other conditions. Young adult populations require special attention for care transitions, particularly in university settings where patients frequently relocate. Importantly, EoE differs from other childhood atopic conditions in that patients do not “grow out of” the disease, and discontinuation of any effective therapy typically results in disease recurrence, emphasizing the importance of maintaining long-term treatment adherence and regular clinical oversight.

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.

Evan Dellon, MD, MPH

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