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Q&A: Pharmacist’s Care of EoE
Q&A: Management of Eosinophilic Esophagitis: Opportunities for Pharmacists to Increase Awareness and Optimize Care

Released: April 12, 2023

Brian A. Hemstreet
Brian A. Hemstreet, PharmD, FCCP, BCPS
Erin Hamai Tom
Erin Hamai Tom, PharmD, APh, MBA, BCACP, CSP
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Key Takeaways
  • Eosinophilic esophagitis (EoE) is a chronic, inflammatory condition that often presents in childhood and continues throughout the lifespan. Left untreated, patients may experience esophageal stricturing, narrowing, fibrosis, and dysphagia.
  • A multidisciplinary team can help optimize EoE care through individualized management when considering dietary modifications, esophageal dilation, or use of medications, including topical corticosteroids, proton pump inhibitors, or a biologic agent.
  • Dupilumab recently became the only FDA-approved therapy for EoE, offering healthcare professionals an option to decrease symptoms and resolve the histologic damage of the condition.

In this commentary, Dr Brian Hemstreet and Dr Erin Hamai Tom answer questions from attendees of the recent ProCE satellite symposium at the Academy of Managed Care Pharmacy (AMCP) 2023 Meeting, “Management of Eosinophilic Esophagitis: Opportunities for Pharmacists to Increase Awareness and Optimize Care." Watch the on-demand webcast here and download the slides here.

What are the consequences of long-term, untreated inflammation in eosinophilic esophagitis (EoE)?

Brian Hemstreet, PharmD, BCPS, FCCP
The level of inflammation that patients experience early in the disease process coupled with delayed diagnosis can result in long-term complications like esophageal stricturing, narrowing, and then the subsequent need for repeated endoscopy. Adverse consequences can be developmental, but also psychosocial. From a pathophysiologic standpoint, the goal is to arrest the inflammatory process early in order to prevent long-term fibrosis and the complications associated with EoE.

With a dietary elimination strategy, how soon would you see symptoms reappear if the triggering food is reintroduced?

Brian Hemstreet, PharmD, BCPS, FCCP
First, I’d like to emphasize the importance of collaborating with dietitian colleagues when implementing and assessing dietary elimination. In my experience, you can see the recurrence of symptoms within several days to weeks if a food trigger is reintroduced. This is why one approach is starting with the more common food groups that are implicated, such as cow's milk, which is the number one associated allergen. Some ask, "Should we be starting with eliminating everything and reintroducing, versus going for the more common ones first?" But offending food groups tend to become evident very quickly. Often times, this results in patients recognizing triggers before a formal diagnosis is made, making dietary modifications on their own, which may contribute to delays in diagnosis.

How soon after initiation of an elimination diet should a patient have a repeat endoscopy to measure its impact?

Brian Hemstreet, PharmD, BCPS, FCCP
There may be little correlation between patient symptoms and histologic improvement, with both outcomes being important. It is therefore important to include both when measuring the success of a particular therapy. The literature is varied on a recommended follow-up endoscopy. Typically, a 2- to 3-month timeframe to repeat endoscopy is reasonable. With monitoring, healthcare professionals (HCPs) should ask, “Does the patient have improvement in symptoms? And after elimination of that food, do they have histologic improvement as well?” It is key to ensure that the patient has been adherent with the diet prior to reassessing them. If there is no histologic improvement, one would then consider if eliminating another food group is the best next step or if a different therapeutic approach would be more appropriate. This process of implementing food changes and repeating endoscopies may take several months to complete.

Is there a role for combination therapy? For example, would you combine any of the following: elimination diet, topical corticosteroids, proton pump inhibitors (PPIs), and/or a biologic agent like dupilumab?

Erin Hamai Tom, PharmD, APh, MBA, BCACP, CSP
Yes, HCPs can try any combination of therapy. Sometimes it's helpful to use a combination to bridge a patient over to a new therapy, for example, use of a biologic and PPI. If the patient wasn't responsive to PPI therapy and you confirm they still have a high eosinophil count via biopsy, you can start a biologic, then titrate off that PPI. In practice, I typically use a combination for a short period of time. Also, if the patient is interested in cutting down the number of medications they take or you deem one not to be effective, the agent should be discontinued.

Are there patients in whom you would go straight to a biologic agent? With other potential therapies having less benefit with efficacy and potentially undesired burdens associated with their use for some patients, could dupilumab be started first? Would you initiate dupilumab first in a patient with comorbid conditions also treated by that agent, like atopic dermatitis or asthma? 

Erin Hamai Tom, PharmD, APh, MBA, BCACP, CSP
Like many conditions, the severity of EoE presents in a spectrum ranging from mild to severe disease. It is key to engage patients in shared decision-making (SDM) and prioritize their preferences and goals in developing the treatment plan. Most certainly, therapy should be individualized with many variables considered when selecting an option. These variables include efficacy and degree of improvement needed to meet therapeutic goals, safety considerations, comorbid conditions, cost, coverage, access to each therapy, ease or preference for route of administration, therapy adherence, and health literacy, and then resultant effects for that patient upon follow-up. Optimal personalization of a plan will also consider that these variables may change over time for each patient as well, so routine follow-up, SDM, and open HCP/patient communication is imperative for overall patient- and disease-related outcomes.

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