Pharmacologic treatment of eosinophilic esophagitis: efficacious, likely efficacious, and failed drugs

Background: Treatment options for Eosinophilic esophagitis (EoE) evolve rapidly. This review focuses on pharmacologic options to treat EoE. Summary: Orodisopersible budenoside tablets (Jorveza®) have been approved by regulatory authorities for EoE treatment of adults in Europe, Canada and Australia, but not the United States. Jorveza®, as compared to placebo, is effective in inducing and maintaining histologic and clinical remission over time. Before the approval of Jorveza®, several investigator-initiated randomized controlled clinical studies evaluated esophagus-targeted formulations of either budesonide or fluticasone to treat pediatric and adult EoE patients. These drugs were generally efficacious in inducing and maintaining histological and clinical remission. Proton-pump inhibitors (PPI) are used off-label for EoE treatment of pediatric and adult EoE patients given that they are able to induce histologic and clinical remission. Dupilumab (Dupixent®), a monoclonal antibody targeted against IL-4 and IL-13, was approved by regulatory authorities in the United States, Europe, Canada, but not yet Australia. In Europe, including Switzerland, Dupixent® is approved to treat EoE patients of at least 12 years of age with at least 40 kg body weight if they are either unresponsive or intolerant to or not candidates for conventional EoE therapies. Due to lack of efficacy or unfavorable safety profile, the following drugs are not recommended for EoE treatment: systemic steroids, sodium cromoglycate, montelukast, azathioprine, TNF-antagonists (eg. infliximab), vedolizumab (mAb against α4β7), benralizumab (mAb against IL-5 receptor), mepolizumab (mAb against IL-5), reslizumab (mAb against IL-5), omalizumab (mAb against IgE), and lirentelimab (mAb against siglec-8). Key messages: Long-term effectiveness and safety data on different drugs are currently sparse. Concerted efforts of different stakeholders will be necessary to continue the endeavour of providing our patients with much-needed therapies.