By Prof. Stephen Attwood, Durham University Hospital, UK.
Eosinophilic Oesophagitis is a disease that has been described only in the past 30 years but it has become an important disease to recognize and treat correctly. It is relatively rare with incidence averaging 8.5/100,000 per annum in western countries, but increasing in frequency.
The key symptom of Eosinophilic Oesophagitis (EoE) is difficulty swallowing solid foods, progressing to strictures in some, food bolus obstructions in others and occasionally to spontaneous perforation of the oesophagus. In emergency departments EoE is the commonest cause of food bolus obstructions requiring emergency endoscopy, and EoE is the commonest cause of spontaneous oesophageal perforation.
For the majority of patients however the main issue is a significant disruption in the quality of life as sufferers cannot eat comfortably, having to adapt their food consistency and avoiding eating in social company.
The only way to make the diagnosis is by endoscopy and biopsy, taking multiple samples from the oesophagus, the diagnosis being confirmed when >15 eosinophils are seen per high power field in the oesophageal squamous mucosa.
I personally have had 30 years of experience in treating EoE. I had the opportunity to write the first paper on this clinic-histologic condition (ref 1) and since then I have run a referral centre for EoE patients with complex needs. I have participated in many major therapeutic trials during the past 15 years and for this reason I have clear insight into the value and limitations of current treatments.
Treatment – Diet, PPI, Corticosteroids
The current options of therapy are not clearly defined. No adequate comparative trials are available to help patients and their doctors. The only fully powered and properly placebo-controlled study is the Lucendo study (ref 2) that identified the value of a dedicated formulation of topical steroid for oesophageal therapy.
Until then patients had a choice of diets or trying drugs in an ad hoc way. Diets initially were elemental but this is not a sustainable way to live a normal life and precludes eating food completely. The option in diet was a 6-food elimination diet but this too is difficult to adhere to and compliance, even in clinical trials, lasts for less than a year. Now, diets excluding limited foods (such as the two-food diet of avoiding milk and wheat) are more practical but are only helpful for 30% of patients because most patients have multiple food triggers.
The drug choices for many years have been PPi and topical steroids. PPi therapy seems to be symptomatically helpful in approximately 50% of patients although in my experience it is less effective in the long-run at preventing stricture and during long term therapy progressive fibrosis still occurs. PPis are cheap and therefore it is common for patients to try them. If their quality of life is acceptable then it is a reasonable long-term therapy as long as those patients get adequate follow up with endoscopy and biopsy to assess progression of the underlying fibrosis.
Budesonide Orodispersible Tablets - Jorveza
For patients whom PPi is not effective, or for those with severe symptoms or already established stricture, topical steroid, using the licensed Orodispersible Budesonide (Jorveza) is the first choice. Since we have had access to this in the past 2 years, we have seen a heartening reduction in stricture development and a reduction in the need for endoscopic dilatation therapy for EoE strictures. We have also seen an dramatic reduction in food bolus obstructions in those patients, improving their quality of life and reducing their burden on the our health services.
Using Jorveza we also see great improvement in quality of life of EoE patients with their ability to restore comfortable eating and normal social behaviour. A recent audit about the quality of life and benefits of using Jorveza has been completed in our University Hospitals group. Similar outcomes have been seen by Dr Jamal Hayatt in St George’s Hospital in London.
I sincerely hope that Jorveza will be available to patients with severe symptoms of EoE. Although more expensive than PPi it is probably cheaper in the long run due to a reduction in planned follow up endoscopies, and reduction in A/E food bolus obstruction visits and perforations. The improvement in quality of life is profound and I believe that patients in a standard health care system deserve to be effectively treated within reasonable costs.
1. Attwood SEA, Smyrk TC, DeMeester TR, et al. Esophageal eosinophilia with dysphagia. A Distinct clinicopathologic syndrome. Dig Dis Sci. 1993; 38: 109–116.
2. AJ Lucendo, S Miehlke, C Schlag, et al. Efficacy of budesonide orodispersible tablets as induction therapy for eosinophilic esophagitis in a randomized placebo-controlled trial. Gastroenterology 2019; 157: 74-86.