Generic Measures of Quality of Life Are Not Correlated with Disease Activity in Eosinophilic Esophagitis

Predictors of persistent symptoms in eosinophilic esophagitis after remission: fibrostenosis, eosinophilia, anxiety, and depression

Eosinophilic Esophagitis (EoE) is a chronic inflammatory esophageal disorder, often associated with dysphagia, chest discomfort, and heartburn. There is limited information on persistent esophageal symptoms despite histologic remission (HR). We aimed to assess the prevalence and predictors of persistent esophageal symptoms in adult patients with EoE in HR. We performed a retrospective cohort study of adult EoE patients in HR (<15 eosinophils per high power field [eos/hpf]). Exclusion criteria included: no available data on symptoms, chronic opiate use, disorders of esophagogastric junction outflow on Chicago Classification version 4 diagnosis, esophageal candidiasis, erosive esophagitis, or other known cause of esophageal dysphagia besides EoE. Based on prior literature, definitions include: complete HR (<5 eos/hpf), partial HR (5-14 eos/hpf), and endoscopic fibrostenosis (rings and/or stricture). Esophageal symptoms were assessed within 2 weeks of HR and categorized into the major symptoms of dysphagia, chest pain, and heartburn. Given the retrospective nature of the study, a global symptom response (absence or presence) was used. Demographics, disease history, endoscopy reports, EoE endoscopic reference score, and histology were recorded. Univariate and multivariable logistic regression analyses were performed. Eosinophil thresholds for persistent symptoms were determined using receiver operating characteristics analyses. Of 289 EoE patients in HR, 133 (46%) had esophageal symptoms: dysphagia (N = 119; 41.2%), heartburn (N = 28; 20.8%), and chest pain (N = 10; 7.5%). Significant predictors for persistent dysphagia were anxiety (adjusted odds ratio [aOR] 3.77) and endoscopic fibrostenosis (aOR 3.87). Significant predictors for persistent heartburn with or without chest pain were anxiety or depression (aOR 12.2 and aOR 11.0) and partial HR (aOR 1.17 and aOR 1.18). Threshold eosinophil counts for persistent heartburn and chest pain were 2.5 and 3.5 eos/hpf, respectively (AUC 0.71 and 0.69). We report a high prevalence of persistent esophageal symptoms in EoE patients who are in HR. Risk factors include anxiety, depression, endoscopic fibrostenosis, and partial HR. These findings can help direct patient care, including endoscopic dilation and managing psychiatric comorbidities. Targeting less than 2.5 and 3.5 eos/hpf for heartburn and chest pain may be warranted.

Dupilumab Improves Health-Related Quality of Life and a Range of Symptoms in Patients With Eosinophilic Esophagitis

INTRODUCTION

Improvements in symptomatic experience and health-related quality of life (HRQoL) are among the most important treatment benefits in patients with eosinophilic esophagitis (EoE). We assessed the impact of dupilumab treatment on HRQoL, patients' impression of dysphagia, and symptoms beyond dysphagia in adults/adolescents (≥12 years) with EoE in parts A and B of the LIBERTY EoE TREET (NCT03633617) study.

METHODS

The EoE Symptom Questionnaire (EoE-SQ; frequency and severity of nondysphagia symptoms), EoE Impact Questionnaire (impact of EoE on HRQoL), and Patient Global Impression of Severity and Patient Global Impression of Change of dysphagia were used to assess the efficacy of weekly dupilumab 300 mg vs placebo.

RESULTS

At week 24, dupilumab reduced EoE-SQ Frequency (least squares mean difference vs placebo [95% confidence interval] part A -1.7 [-2.9, -0.5], part B -1.4 [-2.3, -0.5]; both P < 0.01) and EoE-SQ Severity (part A -2.0 [-3.9, 0.0], P < 0.05, part B -1.5 [-3.0, 0.1], P = 0.07) overall scores, and improved scores across all individual items. Improvement in the dupilumab group was clinically meaningful to patients. Dupilumab also meaningfully improved EoE Impact Questionnaire average scores and improved individual item scores at week 24, particularly emotional and sleep disturbance. More dupilumab-treated patients reported improvement in the Patient Global Impression of Change of dysphagia vs placebo or reported having no symptoms per the Patient Global Impression of Severity of dysphagia at week 24.

DISCUSSION

Dupilumab reduced the impact of EoE on multiple aspects of HRQoL, patients' impression of dysphagia, and frequency and severity of symptoms beyond dysphagia in adults/adolescents with EoE.

Quality of Life Factors in Adults with Eosinophilic Oesophagitis in New Zealand

BACKGROUND

Eosinophilic oesophagitis (EoE) is an immune-mediated oesophageal disorder causing dysphagia. Patients with EoE experience reduced QoL due to symptoms; however, this has not been assessed in the New Zealand population. The aim of this study was to assess QoL in patients with EoE in New Zealand.

METHODS

This observational study recruited participants from two New Zealand hospitals. Records were reviewed to confirm diagnoses, and consenting participants completed an electronic survey, consisting of the Dysphagia Symptom Questionnaire (DSQ) score and the QoL-specific EoE (EoE-QoL-A) questionnaire score. Correlation analysis examined the relationship between the DSQ and EoE-QoL-A scores. Differences in baseline variables were assessed. Univariate logistic regression assessed the association of variables with disease activity and QoL.

RESULTS

Fifty-four participants responded, and four were excluded due to incomplete surveys. The majority (76%) were male, and the median age was 47 years (IQR 42-58). The median DSQ was 49 (IQR 0-60), and the median EoE-QoL-A score was 68 (IQR 48-80). A reduced EoE-QoL-A score was associated with active disease (OR = 0.96,95% CI 0.926-0.995). Significant associations were found between disease activity and overall EoE-QoL-A score (r = -0.37, p < 0.01) as well as the sub-categories eating and diet (r = -0.54, p < 0.001), social (r = 0.30, p < 0.05), and emotional impact (r = -0.44, p < 0.01). The EOE-QoL-A score was higher in those on PPI (75 vs. 60, p = 0.02).

CONCLUSION

This study identified a decreased quality of life (QoL) in individuals with EoE in New Zealand, aligning with international literature. The increased DSQ scores suggest a possible gap in current management approaches. The correlation between the DSQ and QoL highlights the need for improved care models of care for EoE.

Health-Related Quality of Life in Patients with Eosinophilic Esophagitis

Measuring health-related quality of life (HRQOL) gained relevance in research and clinical practice in patients with eosinophilic esophagitis. The physical discomfort and social and psychological consequences of this food-related disease substantially affect HRQOL. Determinant of an impaired HRQOL include symptom severity, disease duration, biological disease activity, and psychological factors. Patients prioritize symptom relief and improved HRQOL as treatment objectives. Available treatment options can address these goals; however, there is a suboptimal adherence to treatment. There is a need for enhanced patient guidance and education. The assessment of HRQOL will help to prioritize patient's needs in management.

Esophageal Hypervigilance and Symptom-Specific Anxiety in Patients with Eosinophilic Esophagitis

BACKGROUND & AIMS

Patient symptom reporting often does not correlate with the pathophysiological markers of esophageal disease, including eosinophilic esophagitis (EoE). Esophageal hypervigilance and symptom-specific anxiety are emerging as important considerations in understanding symptom reporting. As such, we aimed to conduct the first study of these constructs in EoE.

METHODS

A retrospective review of an EoE patient registry was conducted and included eosinophils per high power field (from esophagogastroduodenoscopy biopsy: proximal, distal), endoscopic reference score, distal distensibility plateau (functional luminal imaging probe), Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, Northwestern Esophageal Quality of Life scale, and the Esophageal Hypervigilance and Anxiety Scale. Correlational and regression analyses evaluated relationships of hypervigilance and anxiety with Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, and Northwestern Esophageal Quality of Life scale when controlling for histology and endoscopic severity.

RESULTS

One hundred and three patients had complete data, 69.9% were male, and the mean (SD) age was 40.66 (13.85) years. Forty-one percent had elevated dysphagia and 46% had elevated hypervigilance and anxiety. Esophageal symptom-specific anxiety emerged as the most important predictor of Brief Esophageal Dysphagia Questionnaire severity (44.8% of the variance), Visual Dysphagia Question of EoE Activity Index severity (26%), and poor health-related quality of life (HRQoL) (55.3%). Hypervigilance was also important, but to a lesser extent. Pathophysiological variables did not significantly predict symptoms or HRQoL. Recent food impaction can predict symptom-specific anxiety and proton pump inhibitor use can reduce hypervigilance.

CONCLUSIONS

Hypervigilance and symptom-specific anxiety are important for our understanding of self-reported patient outcomes in EoE. These processes outweigh endoscopic and histologic markers of EoE disease activity across dysphagia, difficulty eating, and HRQoL. Clinicians should assess hypervigilance and anxiety, especially in patients with refractory symptoms and poor HRQoL.

The estimation of a preference-based single index for the IBS-QoL by mapping to the EQ-5D-5L in patients with irritable bowel syndrome

Purpose

The Irritable Bowel Syndrome Quality of Life (IBS-QoL) questionnaire is a commonly used and validated IBS-specific QoL instrument. However, this questionnaire is in contrast to the EQ-5D-5L, not preference-based and as such does not allow calculation of QALYs. The objective of this study was to describe the convergent- and known-group validity of both questionnaires and to develop a mapping algorithm from EQ-5D-5L which enable IBS-QoL scores to be transformed into utility scores for use in economic evaluations.

Methods

We used data from two multicenter randomized clinical trials, which represented the estimation and external validation dataset. The convergent validity was investigated by examining correlations between the EQ-5D-5L and IBS-QoL and the known-group validity by calculating effect sizes. Ordinary least squares (OLS), censored least absolute deviations (CLAD), and mixture models were used in this mapping approach.

Results

283 IBS patients were included (n = 189 vs. n = 84). Mean IBS-QoL score was 71.13 (SD 15.66) and mean EQ-5D-5L utility score was 0.73 (SD 0.19). The overall sensitivity of the IBS-QoL and EQ-5D-5L to discriminate between patient and disease characteristics was similar. CLAD model 4, containing the total IBS-QoL score and squared IBS-SSS (IBS severity scoring system), was chosen as the most appropriate model to transform IBS-QoL scores into EQ-5D-5L utility scores.

Conclusion

This study reports the development of an algorithm where the condition-specific questionnaire IBS-QoL can be used to calculate utility values for use in economic evaluations. Including a clinical measure, IBS-SSS, in the model improved the performance of the algorithm.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02995-y.