Management of refractory eosinophilic esophagitis

Whereas most children and adults respond to traditional eosinophilic esophagitis (EoE) treatments, such as exclusion of dietary allergens or the use of topical steroids, a small fraction may not.

Based on clinical experience and a review of the literature, the aim of this work is to provide practical advice for caring for 'refractory' patients with EoE.

The approach to this type of patient continues to evolve and decision-making should consider a number of issues including the patient's age, lack of a complete understanding of the natural history of this disease, risks of monitoring, and side effects of treatments. Next, one needs to define the term 'refractory' in that this can refer either to persistent symptoms or to continued inflammation in the face of presumably effective drug or diet therapy. Before considering alternative treatments, it is important to rule out any other cause of persistent symptoms. For instance, could they be related to an occult esophageal narrowing not identified at the time of endoscopy? Esophagrams may be necessary to identify localized or longitudinal narrowing that could be amenable to dilation. If symptoms and inflammation persist and no narrowing is appreciated, an elemental diet can be considered; however, the long-term use of this in older children and adults may be difficult. Prednisone or systemic steroids may be indicated to induce remission, but side effects and complications associated with chronic use are limiting. Finally, the use of immunosuppression or biological agents has been reported in case reports and studies; use of these may be limited by side effects or the need to utilize compassionate use protocols.

As the scope of esophageal eosinophilia continues to evolve, the clinical and molecular characterization of new clinical phenotypes will be important so that new therapeutic targets can be identified.