Budesonide Oral Suspension Significantly Improves Eosinophilic Esophagitis Histology Scoring System Results: Analyses From a 12-Week, Phase 2, Randomized, Placebo-controlled Trial

Histopathology of Eosinophilic Esophagitis

Microscopic examination of esophageal biopsies is essential to diagnose eosinophilic esophagitis (EoE). Eosinophil inflammation is the basis for the diagnosis, but additional abnormalities may contribute to persistent symptoms and epithelial barrier dysfunction. Both peak eosinophil count and assessments of additional features should be included in pre-therapy and post-therapy pathology reports. Pathologic abnormalities identified in esophageal biopsies of EoE are reversible in contrast to esophageal strictures.

Medical treatment of eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated eosinophilic inflammatory disease isolated to the esophagus. As a clinicopathologic disorder, a diagnosis of EoE requires a constellation of clinical symptoms of esophageal dysfunction and histologic findings (at least 15 eosinophils/high-powered microscope field (eos/hpf)). Current guidelines no longer require the failure of response to proton pump inhibitor medications to establish a diagnosis of EoE, but continue to suggest the exclusion of other etiologies of esophageal eosinophilia. The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications. Currently, there is no cure for EoE, making long-term treatment necessary. Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy. Effective pharmacologic therapies include corticosteroids, rapidly emerging biological therapies, and proton pump inhibitor medications.

OBJECTIVES

To evaluate the efficacy and safety of medical interventions for people with eosinophilic esophagitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP to 3 March 2023.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of eosinophilic esophagitis, either alone or in combination, to any other intervention (including placebo).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently selected studies and conducted data extraction and risk of bias assessment. We expressed outcomes as a risk ratio (RR) and as the mean or standardized mean difference (MD/SMD) with 95% confidence interval (CI). We assessed the certainty of the evidence using GRADE. Our primary outcomes were: clinical, histological, and endoscopic improvement, and withdrawals due to adverse events. Secondary outcomes were: serious and total adverse events, and quality of life.

MAIN RESULTS

We included 41 RCTs with 3253 participants. Eleven studies included pediatric patients while the rest recruited both children and adults. Four studies were in patients with inactive disease while the rest were in patients with active disease. We identified 19 intervention comparisons. In this abstract we present the results of the primary outcomes for the two main comparisons: corticosteroids versus placebo and biologics versus placebo, based on the prespecified outcomes defined of the primary studies. Fourteen studies compared corticosteroids to placebo for induction of remission and the risk of bias for these studies was mostly low. Corticosteroids may lead to slightly better clinical improvement (20% higher), measured dichotomously (risk ratio (RR) 1.74, 95% CI 1.08 to 2.80; 6 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNTB) = 4; low certainty), and may lead to slightly better clinical improvement, measured continuously (standard mean difference (SMD) 0.51, 95% CI 0.17 to 0.85; 5 studies, 475 participants; low certainty). Corticosteroids lead to a large histological improvement (63% higher), measured dichotomously (RR 11.94, 95% CI 6.56 to 21.75; 12 studies, 978 participants; NNTB = 3; high certainty), and may lead to histological improvement, measured continuously (SMD 1.42, 95% CI 1.02 to 1.82; 5 studies, 449 participants; low certainty). Corticosteroids may lead to little to no endoscopic improvement, measured dichotomously (RR 2.60, 95% CI 0.82 to 8.19; 5 studies, 596 participants; low certainty), and may lead to endoscopic improvement, measured continuously (SMD 1.33, 95% CI 0.59 to 2.08; 5 studies, 596 participants; low certainty). Corticosteroids may lead to slightly fewer withdrawals due to adverse events (RR 0.64, 95% CI 0.43 to 0.96; 14 studies, 1032 participants; low certainty). Nine studies compared biologics to placebo for induction of remission. Biologics may result in little to no difference in clinical improvement, measured dichotomously (RR 1.14, 95% CI 0.85 to 1.52; 5 studies, 410 participants; low certainty), and may result in better clinical improvement, measured continuously (SMD 0.50, 95% CI 0.22 to 0.78; 7 studies, 387 participants; moderate certainty). Biologics result in better histological improvement (55% higher), measured dichotomously (RR 6.73, 95% CI 2.58 to 17.52; 8 studies, 925 participants; NNTB = 2; moderate certainty). We could not draw conclusions for this outcome when measured continuously (SMD 1.01, 95% CI 0.36 to 1.66; 6 studies, 370 participants; very low certainty). Biologics may result in little to no difference in endoscopic improvement, measured dichotomously (effect not estimable, low certainty). We cannot draw conclusions for this outcome when measured continuously (SMD 2.79, 95% CI 0.36 to 5.22; 1 study, 11 participants; very low certainty). There may be no difference in withdrawals due to adverse events (RR 1.55, 95% CI 0.88 to 2.74; 8 studies, 792 participants; low certainty).

AUTHORS' CONCLUSIONS

Corticosteroids (as compared to placebo) may lead to clinical symptom improvement when reported both as dichotomous and continuous outcomes, from the primary study definitions. Corticosteroids lead to a large increase in histological improvement (dichotomous outcome) and may increase histological improvement (continuous outcome) when compared to placebo. Corticosteroids may or may not increase endoscopic improvement (depending on whether the outcome is measured dichotomously or continuously). Withdrawals due to adverse events (dichotomous outcome) may occur less frequently when corticosteroids are compared to placebo. Biologics (as compared to placebo) may not lead to clinical symptom improvement when reported as a dichotomous outcome and may lead to an increase in clinical symptom improvement (as a continuous outcome), from the primary study definitions. Biologics lead to a large increase in histological improvement when reported as a dichotomous outcome, but this is uncertain when reported as a continuous outcome, as compared to placebo. Biologics may not increase endoscopic improvement (dichotomous outcome), but this is uncertain when measured as a continuous outcome. Withdrawals due to adverse events as a dichotomous outcome may occur as frequently when biologics are compared to placebo.

The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders

Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.

Application of the Eosinophilic Esophagitis Histology Scoring System Grade Scores in Patients at British Columbia Children's Hospital

INTRODUCTION

Histologic diagnosis of eosinophilic esophagitis (EoE) involves peak eosinophil counts (PEC) being greater than 15 per high power field. The EoE Histology Scoring System (EoEHSS) was developed to comprehensively evaluate biopsies to better predict symptom and endoscopy response; we aimed to validate the EoEHSS in our provincial registry, where EoEHSS had not been employed.

METHODS

We reviewed 186 esophageal biopsies from 16 patients at diagnosis and follow-up. Statistical analyses were conducted to quantify how grade scores correlate with active EoE status and PEC counts, and each feature's ability to predict active disease.

RESULTS

Nearly all EoEHSS variables were associated with active EoE and high PEC, with basal zone hyperplasia, eosinophil abscesses, and surface epithelial alteration being most predictive in identifying active EoE.

CONCLUSIONS

We validated and demonstrated each EoEHSS variable's strength in tracking traditional PEC counts, resulting in its adoption as a standard reporting element for our research registry.

Eosinophilic esophagitis: Comparison of clinical, endoscopic and histological scoring systems

Background Eosinophilic Esophagitis (EoE) has received increasing attention as a disease entity, and it is now recognized as an important disorder of the Upper Gastrointestinal Tract. Topical corticosteroids (tCS) are effective in clinical-pathological remission induction (RI) and remission maintenance (RM) of active EoE. With scoring systems, such as clinical (SDI), endoscopic (EREFS), and histological (EoEHSS) systems, EoE can be graded, and its disease activity can be assessed.

Objective To discover how closely results within each of the three scoring systems SDI, EREFS, and EoEHSS are correlated between initial diagnosis (ID), RI, and RM, and to determine how well scores from the three systems are intercorrelated at each time point.

Methods Retrospective cohort analysis of patients with active EoE was performed between 2006 and 2020, with follow-up for up to 6 years. SDI, EREFS and EoEHSS scores were recorded at ID, at RI, and in RM. Evaluation employed descriptive statistics, the Friedman test, and Bonferroni-corrected post hoc pairwise comparisons.

Results At RI 29 and at RM 19 EoE patients provided data. Significant correlations were found between EREFS and EoEHSS at RI and in RM. Pairwise comparisons showed significant differences between ID and RI for SDI, for EREFS, and for EoEHSS.

Conclusion The scoring systems tested did not show intercorrelation at ID. Comparison revealed significant differences for SDI, EREFS, and EoEHSS between the systems at ID und RI, but not in RM, during tCS treatment. These results underline the efficacy of tCS (at RI and RM) in the treatment of active EoE.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

BACKGROUND & AIMS

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE.

METHODS

A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity.

RESULTS

Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE.

CONCLUSIONS

A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

BACKGROUND & AIMS

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE.

METHODS

A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity.

RESULTS

Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE.

CONCLUSIONS

A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

Evaluating the Prognostic Implication of the Collins Histology Scoring System in a Pediatric Eastern Ontario Population With Eosinophilic Esophagitis

INTRODUCTION

Collins et al developed a histology scoring system (EoE HSS) to assess multiple pathologic features. The aim of this study is to identify if the EoE HSS can better detect endoscopic and symptom improvement vs the Peak Eosinophilic Count (PEC).

METHODS

A retrospective chart review was performed for patients during 2014-2016. All patients ≤18 years old with a diagnosis of EoE and whose records included initial and follow-up upper gastrointestinal endoscopies were included. Severity and extent of endoscopic features were scored using 8 parameters, from normal to maximum change for each location of the esophageal biopsy.

RESULTS

Forty patients with EoE were included in the study, of which 35 (87.5%) patients demonstrated symptom and 25 (62.5%) endoscopic improvement at the time of follow-up. In the proximal esophagus, the EoE HSS outperformed the change in eosinophil count of the Children's Hospital of Eastern Ontario (CHEO) practice in predicting endoscopic improvement by 16.8% when examining the change in grade and 17.1% when examining the change in stage scores.

CONCLUSIONS

At our institution, adoption of the EoE HSS in assessing biopsies of EoE patients might be warranted, compared to the traditional practice. However, a bigger sample size may give a more robust difference in all locations.

Budesonide Oral Suspension Improves Outcomes in Patients With Eosinophilic Esophagitis: Results from a Phase 3 Trial

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease for which there is currently no pharmacologic therapy approved by the US Food and Drug Administration.

METHODS

In this double-blind, placebo-controlled, phase 3 trial, patients 11-55 years of age with EoE and dysphagia were randomized 2:1 to receive budesonide oral suspension (BOS) 2.0 mg twice daily or placebo for 12 weeks at academic or community care practices. Co-primary endpoints were the proportion of stringent histologic responders (≤6 eosinophils/high-power field) or dysphagia symptom responders (≥30% reduction in Dysphagia Symptom Questionnaire [DSQ] score) over 12 weeks. Changes in DSQ score (key secondary endpoint) and EoE Endoscopic Reference Score (EREFS) (secondary endpoint) from baseline to week 12, and safety parameters were examined.

RESULTS

Overall, 318 patients (BOS, n = 213; placebo, n = 105) were randomized and received ≥1 dose of study treatment. More BOS-treated than placebo-treated patients achieved a stringent histologic response (53.1% vs 1.0%; Δ52% [95% confidence interval (CI), 43.3%-59.1%]; P < .001) or symptom response (52.6% vs 39.1%; Δ13% [95% CI, 1.6%-24.3%]; P = .024) over 12 weeks. BOS-treated patients also had greater improvements in least-squares mean DSQ scores and EREFS over 12 weeks than placebo-treated patients: DSQ, -13.0 (SEM 1.2) vs -9.1 (SEM 1.5) (Δ-3.9 [95% CI, -7.1 to -0.8]; P = .015); EREFS, -4.0 (SEM 0.3) vs -2.2 (SEM 0.4) (Δ-1.8 [95% CI, -2.6 to -1.1]; P < .001). BOS was well tolerated; most adverse events were mild or moderate in severity.

CONCLUSIONS

In patients with EoE, BOS 2.0 mg twice daily was superior to placebo in improving histologic, symptomatic, and endoscopic outcomes over 12 weeks. BOS 2.0 mg twice daily was well tolerated. ClinicalTrials.gov number: NCT02605837.

Development and Validation of Web-Based Tool to Predict Lamina Propria Fibrosis in Eosinophilic Esophagitis

INTRODUCTION

Approximately half of esophageal biopsies from patients with eosinophilic esophagitis (EoE) contain inadequate lamina propria, making it impossible to determine the lamina propria fibrosis (LPF). This study aimed to develop and validate a web-based tool to predict LPF in esophageal biopsies with inadequate lamina propria.

METHODS

Prospectively collected demographic and clinical data and scores for 7 relevant EoE histology scoring system epithelial features from patients with EoE participating in the Consortium of Eosinophilic Gastrointestinal Disease Researchers observational study were used to build the models. Using the least absolute shrinkage and selection operator method, variables strongly associated with LPF were identified. Logistic regression was used to develop models to predict grade and stage of LPF. The grade model was validated using an independent data set.

RESULTS

Of 284 patients in the discovery data set, median age (quartiles) was 16 (8-31) years, 68.7% were male patients, and 93.4% were White. Age of the patient, basal zone hyperplasia, dyskeratotic epithelial cells, and surface epithelial alteration were associated with presence of LPF. The area under the receiver operating characteristic curve for the grade model was 0.84 (95% confidence interval: 0.80-0.89) and for stage model was 0.79 (95% confidence interval: 0.74-0.84). Our grade model had 82% accuracy in predicting the presence of LPF in an external validation data set.

DISCUSSION

We developed parsimonious models (grade and stage) to predict presence of LPF in esophageal biopsies with inadequate lamina propria and validated our grade model. Our predictive models can be easily used in the clinical setting to include LPF in clinical decisions and determine its effect on treatment outcomes.

Responsiveness of a Histologic Scoring System Compared With Peak Eosinophil Count in Eosinophilic Esophagitis

INTRODUCTION

The optimal instrument for assessing histologic disease activity in patients with eosinophilic esophagitis (EoE) is unclear. We assessed the responsiveness of the EoE Histologic Scoring System (EoE-HSS) when compared with that of the peak eosinophil count (PEC).

METHODS

Histopathology slides were obtained from patients with EoE at baseline and after 8 weeks of treatment with swallowed topical budesonide or elimination diet. Two blinded gastrointestinal pathologists scored biopsies on the EoE-HSS, PEC, and 100-mm visual analog scale (VAS) of overall histologic severity. Change was defined as an improvement by ≥0.5 SD in baseline VAS. Responsiveness was quantified using the standardized effect size (SES) and the probability that the index distinguishes a patient with improvement from a patient without improvement, which is the area under the receiver operating characteristic curve (AUC). Longitudinal validity was assessed using Pearson correlations between changes in EoE-HSS and both PEC and VAS.

RESULTS

The EoE-HSS grade (SES 2.18 [95% confidence interval, CI: 1.46-2.88]; AUC 0.73 [95% CI: 0.57-0.84]) and stage (SES 2.07 [95% CI: 1.37-2.77]; AUC 0.73 [95% CI: 0.58-0.84]) were highly responsive, similar to PEC (SES 1.44 [95% CI: 0.80-2.07]; AUC 0.73 [95% CI: 0.58-0.84]). The EoE-HSS grade and stage were more highly correlated with changes in VAS (grade 0.92 [95% CI: 0.86-0.95]; stage 0.89 [95% CI: 0.81-0.94]) than with changes in PEC (grade 0.74 [95% CI: 0.58-0.85]; stage 0.66 [95% CI: 0.47-0.80]).

DISCUSSION

The EoE-HSS is highly responsive, performs similarly to PEC, and is better correlated with changes in overall histologic activity in patients with EoE.

Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS)

BACKGROUND

End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments.

OBJECTIVE

We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE.

METHODS

Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists.

RESULTS

The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life.

CONCLUSIONS

This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.

Factors Associated With Adequate Lamina Propria Sampling and Presence of Lamina Propria Fibrosis in Children with Eosinophilic Esophagitis

BACKGROUND & AIMS

Esophageal biopsies in children with eosinophilic esophagitis (EoE) are often inadequate for assessment of lamina propria and lamina propria fibrosis (LPF). For children with EoE, little is known about the factors associated with adequate lamina propria (aLP) sampling or the relationship among epithelial features in esophageal biopsies with and without LPF. We aimed to evaluate aLP in esophageal biopsies from children with and without EoE, identify factors associated with aLP and LPF, and examine the relationship among epithelial features in biopsies with and without LPF in children with EoE.

METHODS

In a retrospective study, we analyzed clinical, endoscopic, and histologic data from 217 children (124 with EoE and 94 without EoE [controls]) using descriptive statistics, logistic regression, Spearman's correlation, and receiver operating characteristic curve analysis. Active and inactive EoE were defined per the 2011 consensus guidelines.

RESULTS

aLP was observed in biopsies from higher proportion of children with EoE (69%) than controls (31%) (P = .0001). Active EoE was independently associated with aLP (adjusted odds ratio [aOR], 4.23; 95% CI, 1.00-18.13; P = .05). Patient sex (aOR for boys, 8.37; 95% CI, 1.23-56.74; P = .03) and peak eosinophil count (aOR, 1.02; 95% CI, 1.01-1.04; P = .01) were independently associated with LPF. Epithelial features were strongly interrelated in biopsies with LPF, and the presence of specific epithelial features was associated with LPF.

CONCLUSIONS

aLP was observed in a higher proportion of esophageal biopsies from children with EoE than controls. EoE status, patient sex, and peak eosinophil count were associated with aLP sampling and LPF. Given the intricate relationship between epithelial features and LPF, computational models can be developed to identify children with esophageal biopsies without aLP who are at risk for LPF.

Management of Eosinophilic Esophagitis During Oral Immunotherapy

Food allergies are antigen-driven diseases that can lead to IgE-mediated reactions of immediate hypersensitivity (eg, anaphylaxis triggered by a single food) or non-IgE reactions of delayed hypersensitivity such as eosinophilic esophagitis (eg, inability to eat multiple foods manifesting as abdominal pain, choking, dysphagia, vomiting, reflux, food impaction). Although both types of disease have their own unique set of challenges in diagnosis and management, it is a particularly vexing problem when a patient is afflicted by both conditions. This situation can happen when individuals with IgE-mediated food allergy undergo desensitization using currently available forms of oral immunotherapy. In this Grand Rounds Review, we review diagnostic approaches to oral immunotherapy-associated eosinophilic esophagitis, potential relationships between primary and secondary eosinophilic esophagitis, potential management approaches, areas of uncertainty, and upcoming research. Optimally supporting patients in their journey with food allergy requires shared decision making regarding alternative management strategies and the stimulation of robust research.

Treatment of eosinophlic esophagitis with swallowed topical corticosteroids

Eosinophilic esophagitis (EoE) is an emerging chronic local immune-mediated disease of the esophagus. Beside proton pump inhibitors and food-restriction-diets swallowed topical corticosteroids (STC) can be offered as a first line therapy according to current guidelines. This review describes the background and practical management of STCs in EoE. So far, mainly asthma inhalers containing either budesonide or fluticasone have been administered to the esophagus by swallowing these medications “off label”. Recently esophagus-targeted formulations of topical steroids have been developed showing clinicopathological response rates up to 85% - an orodispersible tablet of budesonide has been approved as the first “in label” medication for EoE in Europe in June 2018. Whereas it was shown that disease remission induction of EoE by STCs is highly effective, there is still a lack of data regarding long-term and maintenance therapy. However, current studies on STC maintenance therapy add some movement into the game.

Eosinophilic Esophagitis Histology Remission Score: Significant Relations to Measures of Disease Activity and Symptoms

OBJECTIVES

Eosinophilic esophagitis (EoE) is characterized by remissions and relapses. Guidelines defining remission do not exist and therefore remission is inconsistently identified. We sought to define histology remission in EoE.

METHODS

Esophageal biopsies, obtained at the time the validated pediatric EoE symptoms scores v2.0 (PEESS v2.0) questionnaire was completed (N = 42), were scored using the validated EoE Histology Scoring System. An EoE Histology Remission Score (EoEHRS) was constructed and specified that in all esophageal sites sampled the peak eosinophil count was <15 per high power field (HPF); in addition, neither the total grade (severity of pathology) nor stage (extent of pathology) scores could exceed 3 (possible total maximum score for each was 24). Spearman correlation coefficients were generated for histology/symptom correlations; coefficient range 0.31 to 0.50 was considered moderate.

RESULTS

EoE Histology Scoring System composite and individual feature scores from proximal and distal esophageal biopsies correlated moderately with PEESS v2.0 mean scores (0.48-0.36, P < 0.01), and with scores in the dysphagia (0.39-0.30, P ≤ 0.01), pain (0.48-0.34, P ≤ 0.01), and gastroesophageal reflux disease (0.51-0.32, P ≤ 0.01) domains. Biopsies that met full EoEHRS criteria had reduced biomarkers, specifically expression of the mast cell markers CPA3 and tryptase mRNA, and reduced eosinophil peroxidase deposition (P < 0.03), compared to those with nonremission scores. Subjects whose biopsies met EoEHRS remission criteria reported reduced symptoms for all domains except nausea and vomiting (P ≤ 0.01).

CONCLUSIONS

The EoEHRS correlated with reduced biomarkers of disease activity and reduced symptoms, and therefore may be useful to inform clinical care and interstudy comparisons.

Correlation of endoscopic signs and mucosal alterations in children with eosinophilic esophagitis

BACKGROUND AND AIMS

In children with eosinophilic esophagitis (EoE), the relationship among the endoscopic reference score (EREFS), the histology scoring system (EoEHSS), and the peak eosinophil count (PEC) is incompletely described. Our aim was to determine the relationship among EREFS, EoEHSS, and PEC and develop a predictive model using components of EREFS and EoEHSS for EoE activity.

METHODS

We analyzed 189 paired EREFSs, EoEHSSs, and PECs. Active EoE (aEoE; n = 98) was defined as ≥15 eosinophils per high-power field and inactive EoE (iEoE; n = 91) as <15 eosinophils per high-power field. Spearman correlation (r) with Bonferroni correction was used to assess the relationship between EREFS, EoEHSS and PEC, and a back-transformed average Fisher test was used to determine the statistical significance of the differences. Receiver operating characteristic analysis was used to develop the predictive model.

RESULTS

The relationship between total EREFS and EoEHSS was modest (r = 0.61) but significantly stronger than the correlation between total EREFS and PEC (r = 0.55; P = .04). The relationship between total EREFS and EoEHSS tended to be stronger in aEoE compared with iEoE (r = 0.41 vs 0.24; P = .09). Compared with EREFS, EoEHSS had a significantly higher area under the curve (0.78 vs 0.92; P = .04) to predict aEoE. A combination of furrows, eosinophilic inflammation, basal cell hyperplasia, eosinophilic abscess, and dilated intercellular spaces had an area under the curve of 0.97, accuracy of 98%, sensitivity of 97%, and specificity of 98% to predict aEoE.

CONCLUSIONS

The endoscopy score modestly correlates with the histologic scoring system. Thus, the endoscopy score is not a reliable marker of tissue involvement in EoE. A panel of individual endoscopic and histologic signs hold promise to accurately predict EoE activity.

Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR)

Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.