S884 Comparative Effectiveness of PPI Plus Budesonide, Fluticasone, or Dupilumab in Eosinophilic Esophagitis: Implications for Quality Improvement in Health Care Delivery

Introduction: Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition treated with proton pump inhibitors (PPIs), topical corticosteroids, and biologics such as dupilumab. Budesonide and fluticasone are the most commonly used topical steroids, but limited data exist comparing their effectiveness. With the increasing use of dupilumab in EoE, updated real-world comparisons are necessary. The objective of this study is to compare the real-world effectiveness of PPI + budesonide, PPI + fluticasone, and PPI + dupilumab in achieving histologic remission, symptom resolution, and time to response in adult EoE patients. Methods: A retrospective cohort of 150 adult patients in the West Virginia University healthcare system with biopsy-confirmed EoE (≥15 eos/HPF) was identified using Slicer Dicer (Epic). Patients were evenly divided into 3 treatment groups: PPI + budesonide (N = 50), PPI + fluticasone (N = 50), and PPI + dupilumab (N = 50). Demographics were balanced across groups (50% men, 50% women). Primary outcome was histologic remission (<15 eos/HPF). Secondary outcomes included symptom resolution, duration to symptom resolution, and efficacy of remission in different PPI groups. Statistical comparisons were made using Chi-square and ANOVA. Results: Histologic remission was achieved in 84% of patients receiving PPI + budesonide, 66% with PPI + fluticasone, and 88% with PPI + dupilumab (P = 0.002). Symptom resolution rates were higher in the budesonide (86%) and dupilumab (90%) groups versus fluticasone (68%) (P = 0.001). Time to symptom resolution was shortest in the dupilumab group (mean 6.2 weeks), compared to 9.4 weeks with budesonide and 10.2 weeks with fluticasone (P < 0.001). No significant difference was observed between PPI types (omeprazole, esomeprazole, pantoprazole) (P = 0.47), but higher PPI doses were associated with improved outcomes (P = 0.03). Conclusion: This cohort study demonstrates that PPI + budesonide and PPI + dupilumab are significantly more effective than PPI + fluticasone in inducing histologic remission and improving symptoms in EoE. Dupilumab also resulted in faster clinical response. These findings suggest that a treatment approach favoring budesonide or dupilumab combined with high-dose PPI is best for optimal EoE management, however, larger studies including clinical trials are needed to confirm these findings.