Evolving Management of Eosinophilic Esophagitis: From Diagnosis to Early Intervention - Episode 9
Stepping Up Therapy in EoE and Treatment Approaches in Pediatric Patients
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.
Dupilumab, FDA approved for eosinophilic esophagitis (EoE) in 2022, represents an important step-up therapy option for patients whose condition fails to respond adequately to first-line treatments. The approach to escalating therapy involves systematic assessment of treatment failure across multiple domains: symptomatic response, endoscopic appearance, and histological inflammation. When patients demonstrate refractory disease with persistent eosinophilic inflammation despite initial therapies such as PPIs, topical steroids, or dietary interventions, clinicians consider advancing to dupilumab. Patient preferences regarding injection therapy vs other treatment modalities influence the timing and selection of this escalation strategy.
The presence of multiple atopic conditions significantly impacts treatment decision-making, particularly in multidisciplinary care settings where gastroenterologists collaborate with allergists. As nearly all patients with EoE have concurrent atopic conditions, such as asthma, eczema, food allergies, or seasonal allergies, dupilumab offers the advantage of treating multiple conditions simultaneously. This “killing two birds with one stone” approach can replace multiple medications with different adverse effect profiles, providing comprehensive management for patients with moderate to severe atopic disease burden alongside EoE.
Pediatric treatment considerations center around 3 primary goals: helping patients feel better while ensuring proper growth and development (including eating and swallowing function), avoiding treatments that are worse than the disease itself, and improving tissue appearance through histological resolution. The treatment hierarchy places symptom relief and growth as top priorities, recognizing that endoscopic assessment requires procedures that may not always be necessary. Treatment selection varies across developmental stages, acknowledging that optimal therapy choices may evolve as children mature and as comorbid atopic conditions emerge over time. The availability of dupilumab provides particular value when multiple atopic diseases develop, allowing comprehensive management with a single therapeutic agent rather than multiple condition-specific treatments with varying adherence challenges and adverse effect considerations.
