Less Can Be Enough: Sustained Remission of Pediatric Eosinophilic Esophagitis With Low-Frequency Dupilumab

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease requiring long-term therapy. Dupilumab, an interleukin-4 and interleukin-13 receptor antagonist, is approved for EoE at a weekly 300 mg dosing regimen. However, data on reduced-frequency dosing, especially in pediatric patients, remain limited. This is the case of a 12-year-old girl presented with vomiting, food impaction, and dysphagia. Endoscopy revealed longitudinal furrows and whitish exudates (EREFS 4), and histology confirmed EoE with 75 eosinophils/high-power field (HPF) and high EoEHSS grade and stage scores. Conventional therapies with proton pump inhibitors, topical fluticasone, and an elimination diet achieved only partial improvement. Dupilumab (300 mg every 2 weeks) induced complete clinical, endoscopic (EREFS 0), and histologic remission (EoEHSS grade/stage 0-1, peak < 6 eos/HPF) after 6 months. Given the remission and parental concern about prolonged therapy, the dosing interval was cautiously extended to every 3 weeks as a monitored off-label trial. Topical steroids and dietary restrictions were discontinued. The patient remained asymptomatic and in complete histologic remission for more than 2 years (as of August 2025: EREFS 0, EoEHSS 0, with a peak eosinophil count of ≤ 6 eos/HPF) without any adverse events. This case illustrates that sustained remission of pediatric EoE may be achievable with individualized, response-based dupilumab de-escalation. While promising, this off-label approach requires confirmation in prospective studies before routine implementation.