Increasing Social Vulnerability Impacts Presentation and Decreases Treatment Response in Eosinophilic Esophagitis

Social vulnerability describes relative disadvantage according to demographics, socioeconomic status, and resources. The impact of social vulnerability on eosinophilic esophagitis (EoE) remains unknown. We aimed to determine whether social vulnerability influences EoE presentation or treatment outcomes.

We conducted a retrospective cohort study of patients of any age with newly diagnosed EoE. The social vulnerability index (SVI) was used to estimate patients' relative vulnerability (with higher scores indicating more vulnerability). For patients with topical corticosteroid (tCS) treatment or dietary elimination and a follow-up endoscopy, we assessed histologic, symptomatic, and endoscopic responses. We compared baseline characteristics and post-treatment responses by SVI.

Among 1457 patients, the mean SVI was 0.42 ± 0.26. Patients with higher SVIs frequently presented with atypical symptoms like vomiting (P < .001), abdominal pain (P = .01), or nausea (P = .01). The SVI was similar for patients treated with tCS or dietary elimination (mean 0.41 vs 0.40). However, patients with higher SVIs had decreased histologic response to tCS treatment that persisted after adjusting for confounders (adjusted odds ratio 0.32 for response <15 eosinophils per high-power field; 95% confidence interval: 0.18-0.65). When analyzing SVI by quartiles, patients in the highest quartile (highest social vulnerability) had 58% lower odds of histologic response to tCS compared to patients with the lowest social vulnerability (adjusted odds ratio 0.42, 95% confidence interval: 0.21-0.84). SVI was not associated with histologic response after dietary elimination.

In patients with EoE, higher social vulnerability was independently associated with lower histologic response to tCS. This association warrants further exploration of explanatory factors, including treatment adherence and increased allostatic load.