Paul Feuerstadt, MD

In this episode, ‘Individualizing EoE Treatment Across the Age Spectrum,’ the panelists explore how clinicians balance efficacy, safety, practical treatment demands, and patient preference when selecting therapy. The experts emphasize that even an effective treatment is unlikely to succeed if a patient cannot or will not use it consistently. They discuss tailoring treatment to disease severity and endoscopic findings while considering the feasibility of repeated dosing, dietary restrictions, self-injection, and access.

Individualizing EoE Treatment Across the Age Spectrum

The conversation highlights the importance of understanding where patients are in life. A twice-daily regimen may be particularly challenging for younger adults, while other patients may be uncomfortable with injections or unable to sustain an elimination diet. Establishing trust allows patients to speak candidly about adherence and helps clinicians adapt therapy rather than judging incomplete use.

The faculty then focus on pediatric care and caregiver involvement. Treatment decisions for children require partnership with parents and other caregivers, who often administer therapy and recognize changes in symptoms. The panel reviews the EoE KIDS data with dupilumab, including histologic remission in younger children and maintenance of response through longer follow-up. Faculty also discuss improvements in endoscopic and histologic measures and the importance of achieving control early in children, who may otherwise live with active disease for decades. Growth findings are highlighted as another meaningful consideration when counseling families.

The next episode in this series, ‘Setting Expectations for Long-Term EoE Treatment,’ features the panelists discussing chronic therapy, reassessment, and practical access barriers that can alter the treatment plan.

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The most effective EoE therapy is one that controls disease and fits the patient's life. Age, caregiver involvement, treatment feasibility, efficacy, and safety all shape individualized treatment decisions.

This episode, titled ‘Long-Term Budesonide Oral Suspension Therapy in EoE,’ features panelists reviewing extended data with budesonide oral suspension and discussing what the findings may mean for long-term management. The experts describe outcomes from a study extending to 48 months, including histologic response using both stringent and conventional eosinophil thresholds and sustained improvement in EoE Endoscopic Reference Score.

Long-Term Budesonide Oral Suspension Therapy in EoE

The panel also discusses the practical reality of long-term swallowed corticosteroid use. Some patients in the study underwent dose reductions, while most maintained their dose. Faculty stress that prescribed dosing and actual patient use are not always identical, particularly with a treatment that may require twice-daily administration. They describe documenting what patients are actually taking rather than assuming perfect adherence from the prescription alone.

Safety and tolerability are also reviewed. Treatment-emergent adverse events occurred in many participants, although most were not considered related to therapy. Esophageal candidiasis is highlighted as an important but generally treatable adverse event, with recurrent candidiasis occasionally limiting continued therapy. Overall, the panel interprets the extension findings as evidence that a substantial proportion of patients can achieve and maintain histologic and endoscopic response over the long term with swallowed budesonide therapy.

In the next episode, ‘Individualizing EoE Treatment Across the Age Spectrum,’ panelists will examine how efficacy, safety, treatment feasibility, patient preferences, and pediatric evidence inform shared decision-making.

Long-term EoE control depends on both sustained response and a treatment patients can realistically maintain. Extended BOS data provide insight into histologic remission, endoscopic improvement, and tolerability over several years.

In ‘Applying REMODEL Findings to Esophageal Function in EoE,’ our panel explores findings from the Phase 4 REMODEL study and their potential application in clinical practice. The experts discuss the study's use of esophageal distensibility as an outcome, describing it as a measure of how well the esophagus accommodates a food bolus and emphasizing that it provides information beyond eosinophil counts and dysphagia.

Applying REMODEL Findings to Esophageal Function in EoE

The panel reviews the improvement in esophageal diameter observed with dupilumab compared with placebo, noting that patients with greater baseline narrowing demonstrated larger changes. Faculty emphasize that distensibility is related to, but not synonymous with, fibrosis. The findings therefore provide a promising signal regarding esophageal remodeling and function while longer-term data remain important for understanding effects on fibrotic complications.

In an additional roundtable, the experts discuss how these findings translate across different clinical settings. EndoFLIP can provide an objective assessment of esophageal caliber when available, particularly when symptoms persist despite histologic remission or apparently normal endoscopy. In practices without EndoFLIP, clinicians describe using careful endoscopic assessment, dilation balloons, or bougies to identify subtle narrowing that may otherwise be difficult to appreciate. The panel highlights the clinical significance of increasing esophageal diameter without mechanical dilation and places the reported improvement into the context of the relatively small caliber changes that can meaningfully affect swallowing.

Our next episode, ‘Long-Term Budesonide Oral Suspension Therapy in EoE,’ examines extended efficacy, histologic control, endoscopic response, and tolerability with swallowed corticosteroid therapy.

REMODEL adds esophageal function to the conversation about EoE disease control. Distensibility and esophageal caliber may reveal clinically meaningful changes that symptoms, histology, and visual endoscopy alone cannot fully capture.

In this episode, ‘Defining Treatment Goals and Mechanisms in EoE,’ the panelists explore how meaningful treatment response should be assessed and how available therapies address inflammation through different mechanisms. The experts describe a multidimensional approach incorporating symptoms, endoscopic appearance, and histology. They emphasize that dysphagia alone does not fully capture disease burden because patients may continue adaptive behaviors or experience persistent fibrostenotic symptoms despite histologic improvement.

Defining Treatment Goals and Mechanisms in EoE

Faculty discuss setting clear expectations with patients around objective targets. Histologic response and improvement in the EoE Endoscopic Reference Score can provide measurable evidence of disease control, while quality of life and the ability to return to previously avoided foods or social activities remain important patient-centered goals. The panel notes that these domains do not always improve in parallel, reinforcing the need to interpret them together.

The conversation then turns to mechanisms of treatment. Dupilumab targets signaling within the type 2 inflammatory pathway, including IL-4 and IL-13 signaling, whereas swallowed topical corticosteroids act locally on the esophageal mucosa to suppress inflammation. The faculty compare the systemic pathway-directed effects of biologic therapy with the local anti-inflammatory action of swallowed corticosteroids and note that a systemic biologic may also be relevant in patients with other type 2 inflammatory diseases.

The next episode in this series, ‘Applying REMODEL Findings to Esophageal Function in EoE,’ features the panelists examining esophageal distensibility and how structural and functional outcomes may add to conventional measures of disease control.

Successful EoE treatment requires more than symptom relief. Symptoms, endoscopic improvement, and histologic control provide complementary measures of response while therapeutic mechanisms target inflammation in different ways.

Paul Feuerstadt, MD

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