Long-term treatment of EoE: BOS, BOT, and PPIs

Review by Prof. Humphrey O'Connor (Ireland)

Study Summary 

Eosinophilic Esophagitis (EoE) is a chronic progressive inflammatory disorder that requires ongoing treatment to maintain remission and prevent fibrostenotic complications. Three recent studies published together provide useful guidance on long-term prescribing. In a 4yr US multicentre open label continuation study of Budesonide Oral Suspension (BOS), 2mg twice daily maintained remission in 58.3% of patients. Safety concerns included abnormal ACTH stimulation tests in 10.7% of patients. Bone mineral density remained stable in adolescents. In a similar 3yr European multicentre study of Budesonide Orodispersible Tablets (BOT), 0.5-1mg twice daily maintained remission in 81.9% of patients. Morning cortisol levels were mildly reduced in 3.2% of patients. Mild esophageal candidiasis occurred in both studies. In an updated systematic review and meta-analysis (studies n,73; patients n,7304) PPIs induced EoE remission in almost half of children and adults, and tapering PPI doses maintained remission in 70% of responders.

Commentary 

For patients with EoE who respond well to topical corticosteroids, a large percentage maintain remission with long-term therapy. Concerns remain, however, on systemic safety of topical corticosteroids, particularly for children and adolescents facing the prospect of perhaps lifelong treatment. PPIs also appear effective in the long-term and incidentally were co-prescribed in 77.9% of BOS patients compared with 37.7% of BOT patients, effectively dual-therapy. The BOS and BOT results apply to EoE responders, and ongoing surveillance is needed to monitor efficacy and safety. We also need to know long-term options for corticosteroid/PPI non-responders, be it dietary management and/or biological agents such as dupilumab, and how treatments might be sequenced. Still quite a lot to learn.

Citation

Dellon ES, Katzka DA, Mukkada VA, et al. Long-term safety and efficacy of budesonide oral suspension for eosinophilic esophagitis: A 4-year, phase 3,open-label study. Clin Gastroenterol & Hepatol 2025;23:2155-2166.

Biedermann L, Schlag C, Straumann A, et al. Efficacy and safety of budesonide orodispersible tablets for eosinophilic esophagitis up to 3 years: An open-label extension study. Clin Gastroenterol & Hepatol 2025;23:2144-2154.

Lucendo AJ, Gutierrez-Ramirez L, Tejera-Munoz A, et al. Proton pump inhibitors for inducing and maintaining remission in eosinophilic esophagitis: An updated systematic review and meta-analysis. Clin Gastroenterol & Hepatol 2025;23:2115-2127.

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