S1061 Real-World Dupilumab Initiation and Endoscopic Outcomes in Eosinophilic Esophagitis: Experience From a Tertiary Care Center

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Introduction: Eosinophilic esophagitis (EoE) management has evolved following the U.S. Food and Drug Administration approval of dupilumab in 2022. This study aims to further characterize which patients with EoE are being offered dupilumab and at what point in their disease course, along with real-world endoscopic outcomes after initiating therapy. Methods: This institutional review board-approved retrospective chart review was conducted at a tertiary care center to evaluate patients diagnosed with EoE based on established clinical and histopathologic criteria. Inclusion criteria were starting dupilumab at age greater than 18 years from June 2011 to March 2024. Indications for dupilumab initiation were categorized based on clinical guidance outlined by Aceves, et al. (2023). Pre- and post-endoscopies (EGD), when available, were reviewed for EoE Endoscopic Reference Score (EREFS) and biopsies for peak eosinophil count (PEC). McNemar's and t test were used for statistical analysis. Results: The cohort (N = 42) was 50% men with a median body mass index of 28 (interquartile range 22-31). Median age at EoE diagnosis was 21 years (15-37) and 26 years (20-42) at dupilumab initiation. All had failed prior therapies: proton pump inhibitors (93%), dietary therapy (64%), fluticasone (67%), budesonide (9.5%), and oral steroids (12%). Dupilumab was started for treatment failure (48%), alternate indication (19%), atopy (10%), strictures (10%), preference (10%), or side effects (5%); none received it as first-line therapy. EGDs pre- and post-treatment were available in 28 patients; median interval between procedures was 24 weeks [19-37]. Eleven had strictures initially, 8 of which resolved with confirmed significance by McNemar’s test (χ² = 9.8, P = 0.0018). EREFS improved from 3.74 (standard deviation [SD] 2.00) to 1.58 (SD 1.35); P = 0.00143. PEC fell from 48 to 2 eosinophils per high powered field (median), P < 0.0001. Conclusion: Dupilumab is an effective step-up therapy, showing post-treatment endoscopic improvements, as demonstrated by our findings in strictures, EREFS, and PEC scores. In our cohort, dupilumab was initiated at a median age of 26 years, about 5.5 years later than the median age of initial diagnosis, with patients having attempted multiple prior therapies. Although current guidelines recommend histologic assessment 12-24 weeks after initiation, repeat EGDs in our cohort were delayed with a median of 24 weeks. This delay may reflect scheduling issues, insurance authorization, or delayed symptom improvement. Despite its efficacy, the high cost of biologics and insurance hurdles may limit earlier use of dupilumab in clinical practice.

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