HOW TO TREAT 25
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HOW TO TREAT 25
A B C
PLoS ONE 13 ( 4 )/ CC BY : bit . ly / 3G9Cula
Figure 8 . Achalasia .
A . On endoscopy , the oesophagus appears normal without dilation . However , increased resistance across the oesophagogastric junction is observed in a patient with achalasia .
B . Oesophagography showing a bird-beak appearance with barium remaining in a non-dilated oesophagus .
C . High-resolution manometry showing panoesophageal pressurisation ( achalasia type II ) with elevated integrated relaxation pressure .
( six or fewer eosinophils / hpf ) and dysphagia symptom response compared with 85 % remission ( fewer than five eosinophils / hpf ) after 12 weeks in the BOT trial . 55
Medical therapy to improve fibrous remodelling in patients is currently under investigation . Losartan , an angiotensin II receptor blocker , reduces the signalling of transforming growth factor beta : a cytokine that stimulates the formation of oesophageal narrowing and rings . 56
Biological agents based on monoclonal antibodies utilised in atopic diseases , such as eosinophilic asthma , are favourable for their disease-modifying effect .
Dupilumab , a fully human monoclonal antibody , targets IL-4 and IL-13 cytokines that are critical drivers for EoE . Dupilumab is already used in several conditions , including atopic dermatitis , asthma and chronic rhinosinusitis . A rigorous three-part phase III international multi-centre trial undertaken at 96 sites demonstrated that , in patients who had already been treated with a high-dose PPI and had ongoing active disease , the use of weekly dupilumab resulted in histological remission in 60 % of those who had received weekly dupilumab compared with 5 % who had received placebo . 57 There was also a greater reduction in dysphagia symptom questionnaire scores and endoscopic scores in those participants who received weekly dupilumab compared with placebo . 57 The blockade of immune-mediated signalling pathways , such as JAK-STAT and sphingosine-1 phosphate , in addition to Anti-Siglec-8 antibodies found on the surface of immune cells , is also being researched . 56
There are numerous clinical trials currently being undertaken in Australia that utilise biological agents in the treatment of EoE . These include an anti-IL-13 trial and an anti-thymic stromal lymphopoietin trial .
PROGNOSIS
EOE is a chronic immune-mediated condition that is increasing in incidence and prevalence . 58 A systematic review demonstrated that the mean time from symptom onset to diagnosis was up to 3.5 years in children and eight years in adults . 59
More than one-third of adult patients who were diagnosed with EoE as a child have ongoing dysphagia symptoms requiring management . 59 Some patients may describe
PPI therapy
Remission : continue treatment with effective medication / diet
Figure 9 . Algorithm for therapeutic management of EoE .
Symptomatic patients : dysphagia , food bolus impaction , heartburn , non-cardiac chest pain
Endoscopy + biopsy
Oesophageal biopsy demonstrates 15 or more eosinophils / hpf
Targeted treatment based on careful patient selection
Swallowed topical corticosteroids
Endoscopic assessment for histological remission
No remission : commence alternative option above
Dietary therapy
Evidence of fibrostenotic disease , eg , stricturing
Endoscopic dilation
Adapted from Greuter T et al 2020 39