Loss of Response to Off-Label Swallowed Topical Corticosteroids in Eosinophilic Esophagitis Can be Overcome by a Switch to an Esophageal-Targeted Budesonide Formulation.

INTRODUCTION

Swallowed topical corticosteroids (STCs) are effective in treating patients with eosinophilic esophagitis. However, real-world data about loss of response to STC are limited and whether patients with off-label STC (olSTC) failure may achieve histologic remission after a switch to budesonide orodispersible tablets (BOT) is unknown.

METHODS

We analyzed prospectively collected data between 2015 and 2023 from the Swiss Eosinophilic Esophagitis Cohort Study and compared patients with prior histologic olSTC-failure (≥15 eosinophils per high-power field), histologic remission after olSTC (<15 eosinophils per high-power field), and STC-naïve patients before BOT treatment. Furthermore, we evaluated the course of olSTC-failure patients after a switch to BOT and used logistic regression to explore potential associations between patients with olSTC-failure and clinical factors.

RESULTS

A total of 340 patients (76% male, median age = 43 years) with BOT were analyzed. Twenty-six percent had prior olSTC nonresponse, 16% were in remission with prior olSTC, and 58% were STC-naïve. In the multivariable logistic regression, olSTC treatment duration in years (OR 1.37, 95% CI 1.12-1.67, P = 0.002), off-label STC adherence <80% in the last 2 years before BOT (6.30; 1.19-33.29, P = 0.03), and age <30 years (6.57; 1.85-23.37, P = 0.004) were independently associated with histologic nonresponse to olSTC. Histologic or combined remission to BOT was not different in patients with prior olSTC response (n = 44) compared to patients nonresponded to olSTC (n = 66) (77.3% vs 62.1%, P = 0.095 and 61.4% vs 42.4%, P = 0.052).

DISCUSSION: Most patients nonresponding to olSTC are not true corticosteroid-refractory but respond to an esophageal-targeted budesonide formulation. Age below 30 years, longer treatment duration and low adherence are associated with olSTC-failure.