Disease Course of Eosinophilic Esophagitis Under Anti-inflammatory Treatment

Eosinophilic esophagitis (EoE) is a chronic type 2 inflammatory disease of the esophagus that progresses to a fibrotic phenotype when left untreated. Current treatment options aim to control clinical, endoscopic, and histological disease activity. However, as of yet, it remains elusive if achieving disease control, particularly the long-term control of histological disease activity, can prevent the development of disease complications.

We aimed to assess the impact of ongoing histological disease activity on the development of disease complications in adult patients with EoE.

We evaluated prospectively included patients in the Swiss EoE cohort. Data on all patients with ongoing maintenance treatment, and at least 2 follow-up visits, but without concomitant gastroesophageal reflux or strictures at baseline, were analyzed. We compared patients with ongoing histological disease activity versus patients with disease control, with regard to development of disease complications over time (strictures, bolus impactions, and need for treatment escalation). Histological disease activity was defined by a peak eosinophil count of ≥15 eosinophils during all follow-up visits.

We included a total of 151 patients with a median follow-up of 56.0 months (70.9% male, median age 39.0 years). A total of 93 patients (61.6%) were classified as having disease control during follow-up, whereas 58 patients (38.4%) showed ongoing histological disease activity. Development of complications occurred in a total of 108 patients (71.5%), significantly more often in patients with ongoing histological activity compared with patients with disease control (89.7% vs 60.2%, P < .001). This difference was mainly due to higher rates of stricture formation and the need for treatment escalation. Multivariate Cox regression models revealed ongoing histologic disease activity as a significant predictor of the development of complications in the follow-up (hazard ratio [HR]: 2.45, P < .001), particularly for the need for treatment escalation (HR: 2.63, P < .001) and development of strictures (HR: 3.16, P = .025).

Ongoing histological disease activity predicts development of complicating disease course in patients with EoE. Current treatment strategies should aim to control both clinical and histological disease activity to prevent disease complications.