Ascending to New Heights for Novel Therapeutics for Eosinophilic Esophagitis

Etrasimod as a treatment for eosinophilic oesophagitis (VOYAGE): a double-blind, placebo-controlled, randomised, phase 2 trial

BACKGROUND

Novel treatments are needed for eosinophilic oesophagitis. Etrasimod is an oral, once-daily, selective sphingosine 1-phosphate (S1P)1,4,5 receptor modulator in development for the treatment of immune-mediated inflammatory diseases. We assessed efficacy and safety of etrasimod versus placebo in adults with eosinophilic oesophagitis.

METHODS

In this double-blind, randomised, phase 2 trial, patients aged 18-65 years with a previous diagnosis of eosinophilic oesophagitis and histologically active disease from 64 clinical sites (in Australia, Belgium, Spain, Switzerland, and the USA) were randomly assigned (3:3:2) using an interactive web response system to receive oral etrasimod 2 mg or 1 mg or matching placebo for 24 weeks (centrally randomly assigned and double-blind; placebo-controlled period); they continued assigned etrasimod doses or were randomly assigned (1:1) from placebo to etrasimod 2 mg or 1 mg for 28 weeks (extension period). Randomisation was stratified by history of oesophageal dilation and concurrent proton pump inhibitor therapy. The full analysis set and safety set consisted of all randomly assigned patients who received at least one study treatment dose. The primary endpoint was percentage change from baseline in oesophageal peak eosinophil count (PEC) at week 16. Safety was assessed up to week 52. Patients were analysed according to treatment received in the placebo-controlled period and extension period. The trial was registered with ClinicalTrials.gov, NCT04682639, and EudraCT, 2020-003226-23; completed on June 30, 2023.

FINDINGS

Between Dec 15, 2020, and May 27, 2022, 41 patients were randomly assigned to etrasimod 2 mg (20 [49%] females and 21 [51%] males), 39 to etrasimod 1 mg (17 [44%] females and 22 [56%] males), and 28 to placebo (14 [50%] females and 14 [50%] males). 85 (79%) of 108 patients completed the double-blind period, entering the extension period. Median percentage changes from baseline in PEC at week 16 were -58·4% (IQR -86·2 to -26·3) for etrasimod 2 mg (p=0·010 vs placebo), -39·4% (-71·1 to 79·0) for etrasimod 1 mg (p=0·29 vs placebo) and -21·5% (-57·2 to 55·4) for placebo. In the placebo-controlled period, the most common treatment-emergent adverse events were gastrointestinal disorders (11 [27%] of 41 patients in the etrasimod 2 mg group, 13 [33%] of 39 patients in the etrasimod 1 mg group, and 14 [50%] of 28 patients in the placebo group). Bradycardia events, reported by three patients (two [5%] patients in the etrasimod 2 mg group and one [4%] in the placebo group) in the placebo-controlled period, were mild or moderate in severity. No serious treatment-emergent adverse events or deaths occurred.

INTERPRETATION

Etrasimod led to sustained histological and endoscopic improvements in eosinophilic oesophagitis over 52 weeks, symptom improvement in patients without dilation, and was well tolerated. This trial provides the first evidence that targeting the S1P pathway can improve disease activity in patients with eosinophilic oesophagitis and that S1P receptor modulation is a viable treatment target for this disease.

FUNDING

Pfizer.

Italian EoExpert panel recommendation for disease control, switching criteria, and follow-up in eosinophilic esophagitis from pediatric to adult age

Background

Eosinophilic esophagitis (EoE) is a chronic, progressive type 2 inflammatory disorder of the esophagus, characterized by abnormal eosinophil accumulation in esophageal epithelium. Undiagnosed or undertreated EoE leads to increased risk of fibrostenosis, strictures, and food impaction due to persistent inflammation, deeply impacting patients' health-related quality of life (HRQoL).

Objectives

To gather insights on comprehensive assessment of EoE, comprising clinical, endoscopic, histological outcomes, adaptive behaviors and HRQoL; to define proper evaluation of disease control and impact of continuous versus noncontinuous treatment to reach full disease control. Finally, to validate an algorithm for disease control, switching criteria, and follow-up.

Design

Literature review, survey, and panel expert opinion building by a multidisciplinary Italian EoExpert Panel (EoExpert) of nine specialists from various Italian institutions.

Methods

Non-systematic literature review, followed by a survey including 21 questions on the different topics. Results were then discussed and validated by EoExpert.

Results

The current diagnostic pathway often does not allow early detection of EoE patients, especially in the presence of adaptive behaviors and unawareness of EoE best practices. In addition, there is a lack of a shared "control" definition. EoExpert reviewed, shared, and recommended two novel management tools for EoE, represented by I.M.P.A.C.T. Questionnaire to uncover adaptive behaviors and S.C.O.P.E. (Symptoms Control, Observation, Pathological Evaluation) scheme for comprehensive treatment efficacy evaluation. EoExpert's recommendations were gathered and turned into a therapeutic management algorithm for the definition of disease control and switching criteria.

Conclusion

This document provides a standardized approach to EoE management in pediatric and adult settings, highlighting the importance of timely diagnosis in a multidisciplinary setting, of using unified criteria for assessment of disease control through the adoption of a comprehensive approach and of following up patients. These recommendations highlight the critical role of increased awareness and standardized care in EoE clinical setting for lifelong management.

Endoscopic response to topical steroids is associated with a need for fewer future esophageal dilations

The eosinophilic esophagitis (EoE) Endoscopic Reference Score (EREFS) measures endoscopic severity. While a score of ≤2 has been proposed for endoscopic response, it is unknown whether achieving this threshold results in clinically important outcomes. We aimed to determine whether an EREFS response to topical steroids (tCS) is associated with a decreased need for future esophageal dilation. In this retrospective cohort study, we included patients with a new diagnosis of EoE who underwent esophageal dilation, were then treated with tCS, and had at least two follow-up endoscopies. Endoscopic response was defined as EREFS ≤2. Histological and global symptom responses were recorded. We compared patients with and without endoscopic response and calculated the number of subsequent dilations in each group. Of 113 EoE patients, 55 (49%) had endoscopic response post-tCS. Compared to endoscopic non-responders, responders were older (43.4 vs 34.4 years; p = 0.001) and had lower EREFS (4.4 ± 1.6 vs. 6.3 ± 1.5; p < 0.001) at baseline. EREFS responders required fewer dilations on their initial post-treatment endoscopy (65% vs 90%; p = 0.002) and had greater symptom (92% vs 64%; p = 0.005) and histologic responses (82% vs 24% <15 eos/hpf; p < 0.001). Over the median follow-up time of 1106 days, EREFS responders required fewer dilations than non-responders (4.5 ± 2.9 vs 6.2 ± 4.5; p = 0.03). Endoscopic responders to tCS required fewer esophageal dilations compared to non-responders. Responders also had better symptom and histologic responses. These results provide evidence that endoscopic response is associated with important clinical outcomes including a reduction in future esophageal dilations.

Histologic Response or Endoscopic Normalization After Initial Treatment for Eosinophilic Esophagitis in Children Leads to Less Fibrostenosis over Long-Term Follow-Up

BACKGROUND

Untreated eosinophilic esophagitis (EoE) can result in the development of fibrostenosis over time, but there are few data on whether successful treatment in childhood decreases this risk as children with EoE transition to adulthood.

AIM

To determine whether histologic response or endoscopic normalization after EoE treatment is associated with decreased development of fibrostenosis.

METHODS

Pediatric subjects were identified from a large EoE database at an academic referral center. Medical records were reviewed for the primary outcome of fibrostenosis, defined as esophageal stricture, narrowing, or dilation. We assessed the proportion of histologic responders and normal endoscopies at the first, second, and last esophagogastroduodenoscopy (EGD) on record following diagnosis. We created Kaplan-Meier curves to assess time to fibrostenosis and estimated hazard ratios using Cox proportional analysis.

RESULTS

Among 166 patients, the mean age at diagnosis was 10.2 years. Over a mean follow-up time of 4.7 ± 4.5 years, patients had an average of 4.3 ± 4.2 EGDs. The percent of patients with fibrostenosis was 9%, 15%, and 16% at first, second, and last EGD. Patients with histologic response at second follow-up developed fibrostenosis at a lower rate than non-responders (HR = 0.37, 95% CI 0.14-0.99), as did those with normal endoscopic findings at first follow-up (HR = 0.27, 95% CI 0.08-0.90).

CONCLUSIONS

Histologic response and endoscopic normalization lead to lower rates of fibrostenosis in children with EoE. Though the development of fibrostenosis was relatively uncommon, occurring in < 20% of children with EoE who were followed long term, it is reasonable to target treatment goals of histologic response and endoscopic normalization.

Roads to remission: evolving treatment concepts in type 2 inflammatory diseases

Non-communicable diseases (NCDs) characterised by type 2 inflammation, including asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, atopic dermatitis, food allergies and eosinophilic esophagitis, are increasing in prevalence worldwide. Currently, there is a major paradigm shift in the management of these diseases, towards the concept of disease modification and the treatment goal remission, regardless of severity and age. Remission as a treatment goal in chronic inflammatory NCDs was first introduced in rheumatoid arthritis, and then adopted in other non-type 2 inflammatory diseases. Among diseases with type 2 Inflammation, this concept is novel and currently most advanced in asthma. This new paradigm has been developed based on a better understanding of the pathophysiology of type 2 inflammation and the advent of highly effective drugs selectively interfering with type 2 pathways. Here, we review the evolution of the new remission concepts in type 2 inflammatory diseases and discuss associated challenges and future research needs.

Funding

None.

Meta-Analysis: Evaluating Placebo Rates Across Outcomes in Eosinophilic Oesophagitis Randomised Controlled Trials

BACKGROUND

High placebo responses have limited drug development in eosinophilic oesophagitis. The optimal configuration of trial outcomes is uncertain.

AIMS

To inform more efficient future trial designs, to characterise clinical, endoscopic and histologic placebo responses in eosinophilic oesophagitis randomised controlled trials (RCTs).

METHODS

We updated a Cochrane systematic review and meta-analysis, searching multiple databases to January 1, 2024, to identify placebo-controlled RCTs evaluating medical therapies for patients with eosinophilic oesophagitis. The primary outcome was the pooled proportion of study-defined clinical, endoscopic and histologic responders and remitters randomised to placebo, using an intention-to-treat approach and random-effects model. Sources of heterogeneity were explored using meta-regression.

RESULTS

We included 25 RCTs. The pooled proportion of clinical response was 41.0% [95% CI: 29.7%-52.8%] with substantial heterogeneity (I2 = 74.9%). On meta-regression, older age and a higher probability of being randomised to placebo reduced the likelihood of clinical response to placebo. The pooled proportion of histologic remission defined as a peak eosinophil count [PEC] ≤ 6 eosinophils per high power field [HPF] or ≤ 1 eosinophil/HPF was 4.3% [95% CI: 2.6%-6.2%] (I2 = 23.6%) and 1.3% [95% CI: 0.5%-2.5%] (I2 = 0%), respectively. The standardised mean difference in the Eosinophilic Oesophagitis Endoscopic Reference Score to placebo was -0.25 [95% CI: -0.41, -0.10].

CONCLUSIONS

Over 40% of patients in eosinophilic oesophagitis trials respond clinically to placebo, and this is associated with trial design factors such as randomisation ratio and trial population. Objective endoscopic and histologic measures are associated with very low placebo responses.

Assessment of Disease Activity in Eosinophilic Esophagitis: Is It Clinically Relevant or Simply an Amusement for Experts?

Background

Since the first description of eosinophilic esophagitis (EoE) as clinicopathologic syndrome three decades ago, considerable progress has been made to standardize and validate instruments to assess symptom severity, quality of life, endoscopic, and histologic activity for the purpose of randomized controlled trials (RCTs) and observational studies. Standardized assessment of EoE activity is crucial to be able to compare the results of therapeutic interventions and bring much needed therapies to patients. This review focuses on outcome assessment of disease activity in adults with EoE.

Summary

The choice of endpoints/instruments to be used depends on the setting, which might be either an RCT, an observational study, or clinical practice. In RCTs, the choice of endpoints further depends on requirements from regional regulatory authorities. Primary endpoints chosen in RCTs typically focused on symptoms and esophageal peak eosinophil counts, although that likely will change, as therapies with new mechanism of action are explored. Validated symptom-based PRO instruments used in RCTs include the Daily Symptom Questionnaire (DSQ), the EoE activity index (EEsAI) PRO instrument, and numeric rating scales for dysphagia and pain. Histologic activity in RCT is assessed using the EoE histologic scoring system (EoEHSS) that takes into account the severity and extent of eight distinct histologic features. Endoscopic activity is assessed using the EREFS (Exudates, Rings, Edema, Furrows, Stricture) grading system. For observational studies, activity assessment is based on EEsAI PRO, epithelial peak eosinophil counts, and EREFS. In daily clinical practice, EoE activity is based on assessment of symptoms using a visual analog scale (VAS, from 0-10), peak eosinophil count, and EREFS. Several other instruments including the I-SEE, dysphagia-free days over a defined period, the dysphagia stress test, and impedance planimetry (EndoFLIP), to assess EoE severity in clinical practice are currently under evaluation.

Key Messages

EoE activity assessment based on symptom-based PRO, histology, and endoscopy has become increasingly complex and varies depending on the setting. While more stringent endpoints and daily recall PRO instruments are being used in RCTs, new instruments aimed at broader disease activity assessment and weekly recall PRO instruments are being used in observational studies and daily clinical practice.

The Minimally Invasive 1-Hour Esophageal String Test Monitors Therapeutic Changes in Mucosal Inflammation in Eosinophilic Esophagitis

INTRODUCTION

Endoscopy, standard-of-care for monitoring eosinophilic esophagitis (EoE), assesses mucosal inflammation. The Esophageal String Test (EST), a minimally invasive swallowed capsule and immunoassays, quantifies EoE inflammation. We determined whether the EST/EoEScore can monitor disease in patients undergoing treatment.

METHODS

Thirty-three samples from 14 patients with EoE (7 children, 7 adults) who underwent repeat endoscopies and ESTs were studied. Biopsies were analyzed for peak eosinophil counts; ESTs were analyzed for EoEScores.

RESULTS

Eosinophil counts and EoEScores significantly correlated during treatment, distinguishing patients with active EoE from treatment-associated remissions for 93.9% of ESTs performed.

DISCUSSION

The EST can be used to longitudinally monitor responses to treatment in EoE.

Efficacy and Safety of Budesonide Orodispersible Tablets for Eosinophilic Esophagitis up to 3 Years: An Open-Label Extension Study

BACKGROUND & AIMS

Budesonide orodispersible tablets (BOT) have been shown to be safe and effective in phase III double-blind trials of induction and 48-week maintenance therapy of eosinophilic esophagitis (EoE). We now analyzed the long-term efficacy and safety of BOT in a 96-week open-label extension (OLE) study.

METHODS

All patients with EoE in the 48-week double-blind maintenance study were eligible to receive BOT treatment for up to 96 weeks. Dosage was 0.5 or 1.0 mg BOT, twice daily, at investigator's discretion. Clinical, histologic, endoscopic, quality of life, and safety measures were assessed.

RESULTS

A total of 186 patients participated in the OLE up to 96 weeks. At week 96, 81.9% of patients had clinical remission, defined as an EoE Symptom Activity Index (EEsAI) score of ≤20 vs 77.7% at OLE baseline. A further 80.1% of patients were in histologic remission, defined as peak eosinophils per high-power field of <5, at week 96 vs 91.8% at OLE baseline. Mean EoE endoscopic reference scores (EREFS) were 1 at all time points measured. Mean EoE Quality of Life (EoE-QoL-A) Scale scores improved from 3.3 at OLE baseline to 3.5 at week 96. No new safety concerns were observed across 96 weeks of treatment. Suspected symptomatic candidiasis occurred at similar rates to prior BOT studies and was predominantly mild and resolved with treatment.

CONCLUSIONS

Clinical and histologic remission of EoE could be maintained with BOT in a large majority of patients for up to 96 weeks, and for up to 144 weeks in patients with uninterrupted BOT therapy across all trials. No additional safety concerns were identified with long-term BOT treatment (ClinicalTrials.gov, Number: NCT02493335).

Tissue-specific inducible IL-33 expression elicits features of eosinophilic esophagitis

BACKGROUND

IL-33 is a type 2 inflammatory cytokine that is elevated in the esophageal epithelium of eosinophilic esophagitis (EoE) subjects. We previously developed a mouse model of EoE dependent on constitutive overexpression of IL-33 from the esophageal epithelium (EoE33).

OBJECTIVE

Our objective was to develop an inducible, IL-33-dependent model of EoE and examine induction of EoE-associated pathology.

METHODS

We utilized a tetracycline-inducible system to express IL-33 in the esophagus by generating 2 transgenic mice. The first (iSophagus) expresses a reverse tetracycline transactivator from the esophageal epithelium. The second (TRE33) features a tetracycline response element driving expression of IL-33. When crossed, these mice generate an inducible model of EoE (iEoE33). Mice were administered doxycycline-infused chow for up to 2 weeks. Cytokines were assessed by ELISA or bead-based multiplex analysis. T cells were assessed by flow cytometry. Pathology was assessed by histology and immunohistochemistry for IL-33, eosinophil peroxidase, CD4, and Ki-67. iEoE33 was treated with steroids and crossed with IL-13-/- mice.

RESULTS

Doxycycline-treated iEoE33 mice demonstrated expression of IL-33 in the esophageal epithelium, and esophageal pathology including eosinophilia, CD4+ cell infiltrate, basal zone hyperplasia, and dilated intercellular spaces. These findings became pronounced on day 7 of induction, were accompanied by weight loss and esophageal thickening, and were steroid responsive and IL-13 dependent.

CONCLUSION

Inducible IL-33 expression in the esophageal epithelium elicited features pathognomonic of EoE. iEoE33 enables investigation of EoE disease mechanisms as well as initiation, progression, and resolution.

Differential changes in mast cells with food reintroduction in children with eosinophilic esophagitis

Intraepithelial mast cells (MCs) are increased in eosinophilic esophagitis (EoE) and reduced with elimination of dietary antigens. Single food reintroduction can identify triggers of eosinophilia; however, the extent to which specific foods trigger intraepithelial mastocytosis remains unknown. We hypothesized that specific foods drive different degrees of MC inflammation. We previously reported a prospective pediatric EoE cohort treated with a 4-food elimination diet (4FED) with removal of soy, egg, wheat, and milk. We retrieved unstained slides in which baseline, 4FED, and post-4FED diet reintroduction time points were available. Slides were stained with tryptase, and intraepithelial MCs were counted. Comparisons were made by stratifying patients by eosinophilia, basal cell hyperplasia (BCH), endoscopic abnormalities, and symptoms. Pearson correlation was assessed for MCs with eosinophilic, endoscopic, and BCH severity; symptoms; and a novel mucosal activity score combining endoscopic and histologic structural severity. Slides were available from 37 patients with at least 1 food reintroduced. MCs were significantly reduced with 4FED. Wheat led to increased intraepithelial MCs in the upper esophagus and with food-induced eosinophilia, while milk led to significantly increased MCs in the upper and lower esophagus and was significantly associated with patients with food-triggered eosinophilia, endoscopic abnormalities, BCH, and symptoms. MCs best correlated with the mucosal activity score during milk reintroduction. In children with EoE, MCs are reduced with 4FED. During milk reintroduction, significant increases in MCs were observed with all metrics of inflammation along with moderate correlation with structural mucosal activity that was not seen with other foods. This suggests that milk exerts unique effects either directly or indirectly on MCs in the esophagus in EoE patients.

Advances and ongoing challenges in eosinophilic gastrointestinal disorders presented at the CEGIR/TIGERs Symposium at the 2024 American Academy of Allergy, Asthma & Immunology meeting

The Consortium of Eosinophilic Gastrointestinal disease Researchers (CEGIR) and The International Gastrointestinal Eosinophil Researchers (TIGERs) organized a daylong symposium at the 2024 annual meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured new discoveries in basic and translational research as well as debates on the mechanisms and management of eosinophilic gastrointestinal diseases. Updates on recent clinical trials and consensus guidelines were also presented. We summarize the updates on eosinophilic gastrointestinal diseases presented at the symposium.

Biologic therapy in rare eosinophil-associated disorders: remaining questions and translational research opportunities

Rare eosinophil-associated disorders (EADs), including hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, and eosinophilic gastrointestinal disorders, are a heterogeneous group of conditions characterized by blood and/or tissue hypereosinophilia and eosinophil-related clinical manifestations. Although the recent availability of biologic therapies that directly and indirectly target eosinophils has the potential to dramatically improve treatment options for all EADs, clinical trials addressing their safety and efficacy in rare EADs have been relatively few. Consequently, patient access to therapy is limited for many biologics, and the establishment of evidence-based treatment guidelines has been extremely difficult. In this regard, multicenter retrospective collaborative studies focusing on disease manifestations and treatment responses in rare EADs have provided invaluable data for physicians managing patients with these conditions and helped identify important questions for future translational research. During the Clinical Pre-Meeting Workshop held in association with the July 2023 biennial meeting of the International Eosinophil Society in Hamilton, Ontario, Canada, the successes and limitations of pivotal multicenter retrospective studies in EADs were summarized and unmet needs regarding the establishment of guidelines for use of biologics in rare EADs were discussed. Key topics of interest included (1) clinical outcome measures, (2) minimally invasive biomarkers of disease activity, (3) predictors of response to biologic agents, and (4) long-term safety of eosinophil depletion. Herein, we report a summary of these discussions, presenting a state-of-the-art overview of data currently available for each of these topics, the limitations of the data, and avenues for future data generation through implementation of multidisciplinary and multicenter studies.

Eosinophil Depletion with Benralizumab for Eosinophilic Esophagitis

BACKGROUND

Benralizumab is an eosinophil-depleting anti-interleukin-5 receptor α monoclonal antibody. The efficacy and safety of benralizumab in patients with eosinophilic esophagitis are unclear.

METHODS

In a phase 3, multicenter, double-blind, randomized, placebo-controlled trial, we assigned patients 12 to 65 years of age with symptomatic and histologically active eosinophilic esophagitis in a 1:1 ratio to receive subcutaneous benralizumab (30 mg) or placebo every 4 weeks. The two primary efficacy end points were histologic response (≤6 eosinophils per high-power field) and the change from baseline in the score on the Dysphagia Symptom Questionnaire (DSQ; range, 0 to 84, with higher scores indicating more frequent or severe dysphagia) at week 24.

RESULTS

A total of 211 patients underwent randomization: 104 were assigned to receive benralizumab, and 107 were assigned to receive placebo. At week 24, more patients had a histologic response with benralizumab than with placebo (87.4% vs. 6.5%; difference, 80.8 percentage points; 95% confidence interval [CI], 72.9 to 88.8; P<0.001). However, the change from baseline in the DSQ score did not differ significantly between the two groups (difference in least-squares means, 3.0 points; 95% CI, -1.4 to 7.4; P = 0.18). There was no substantial between-group difference in the change from baseline in the Eosinophilic Esophagitis Endoscopic Reference Score, which reflects endoscopic abnormalities. Adverse events were reported in 64.1% of the patients in the benralizumab group and in 61.7% of those in the placebo group. No patients discontinued the trial because of adverse events.

CONCLUSIONS

In this trial involving patients 12 to 65 years of age with eosinophilic esophagitis, a histologic response (≤6 eosinophils per high-power field) occurred in significantly more patients in the benralizumab group than in the placebo group. However, treatment with benralizumab did not result in fewer or less severe dysphagia symptoms than placebo. (Funded by AstraZeneca; MESSINA ClinicalTrials.gov number, NCT04543409.).

Esophageal Remodeling Correlates With Eating Behaviors in Pediatric Eosinophilic Esophagitis

INTRODUCTION

There are limited data characterizing eating habits among pediatric patients with eosinophilic esophagitis (EoE). We compared eating behaviors in pediatric patients with EoE with healthy controls and assessed the degree of correlation with symptomatology, endoscopic and histologic findings, and esophageal distensibility.

METHODS

We conducted a prospective, observational study where subjects consumed 4 food textures (puree, soft solid, chewable, and hard solid) and were scored for eating behaviors including number of chews per bite, sips of fluid per food, and consumption time. Symptomatic, endoscopic, histologic, and esophageal distensibility data were collected for case subjects.

RESULTS

Twenty-seven case subjects and 25 healthy controls were enrolled in our study (mean age 11.0 years, 63.5% male). Compared with healthy controls, pediatric patients with EoE demonstrated more chews per bite with soft solid (13.6 vs 9.1, P = 0.031), chewable (14.7 vs 10.7, P = 0.047), and hard solid foods (19.0 vs 12.8, P = 0.037). Patients with EoE also demonstrated increased consumption time with soft solid (94.7 vs 58.3 seconds, P = 0.002), chewable (90.0 vs 65.1 seconds, P = 0.005), and hard solid foods (114.1 vs 76.4 seconds, P = 0.034) when compared with healthy controls. Subgroup analysis based on disease status showed no statistically significant differences in eating behaviors between active and inactive EoE. Total endoscopic reference score positively correlated with consumption time ( r = 0.53, P = 0.008) and number of chews ( r = 0.45, P = 0.027) for chewable foods and with number of chews ( r = 0.44, P = 0.043) for hard solid foods. Increased consumption time correlated with increased eosinophil count ( r = 0.42, P = 0.050) and decreased esophageal distensibility ( r = -0.82, P < 0.0001).

DISCUSSION

Altered eating behaviors including increased chewing and increased consumption time can be seen in pediatric patients with EoE, can persist despite histologic remission, and may be driven by changes in esophageal distensibility.

Endoscopic and histologic utility of transnasal endoscopy in pediatric eosinophilic esophagitis

Unsedated transnasal endoscopy (TNE) is an alternative method of examining the esophageal mucosa in pediatric patients with eosinophilic esophagitis (EoE), reducing cost, time, and risk associated with frequent surveillance esophagogastroduodenoscopies (EGD). Adequacy of transnasal esophageal biopsies for the evaluation of eosinophilic esophagitis histologic scoring system (EoEHSS) has not yet been evaluated. We compared procedure times, endoscopic findings, and EoEHSS scoring for EoE patients undergoing TNE versus standard EGD. Sixty-six TNE patients and 132 EGD controls matched for age (mean age 14.0 years) and disease status (29.3% active) were included. Compared to patients undergoing standard EGD, patients undergoing TNE spent 1.94 h less in the GI suite (p < 0.0001), with comparable occurrence rates of all visual endoscopic findings and most EoEHSS components. TNE serves as a useful tool for long-term disease surveillance, and consideration should be given to its use in clinical trials for EoE.