S970 Dupilumab Outperforms Swallowed Steroids in PPI Refractory EoE: Insights From a Real-World Cohort

Introduction: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition often treated with proton pump inhibitors (PPIs). However, a subset of patients exhibit persistent symptoms and inflammation despite PPI therapy and are considered to have PPI-refractory EoE. In such cases, swallowed topical corticosteroids (STC) and dupilumab—a monoclonal antibody recently approved for EoE—are therapeutic options. Real-world comparative data between these treatments remain limited. This study evaluated the effectiveness of dupilumab versus STC in patients with PPI-refractory EoE, using clinical, endoscopic, and histologic outcomes. Methods: We conducted a retrospective cohort study of adult patients with PPI-refractory EoE treated with either dupilumab or STC at a large tertiary care center. Data collected included demographics, medical history, endoscopic findings, and clinical dysphagia scores. Outcomes assessed were changes in peak eosinophil counts per high-power field, Eosinophilic Esophagitis Endoscopic Reference Scores (EREFS), and clinical dysphagia scores. Comparative analyses were performed using t tests for continuous variables and Chi-square or Fisher’s exact tests for categorical variables. A P-value < 0.05 was considered statistically significant. Results: Thirty-five patients were included (dupilumab N = 18; STC N = 17). Baseline characteristics were similar between groups in age (39.6 ± 16.0 vs 45.6 ± 13.2 years; P = 0.227), sex (72% vs 65% men; P = 0.725), and race (P = 0.212). Pre-treatment eosinophil counts, EREFS, and dysphagia scores were comparable. Post-treatment, patients on dupilumab showed significantly greater reductions in peak eosinophil counts compared to those on STC (-83.1 ± 52.9 vs -43.4 ± 32.3; P = 0.012). Dupilumab was also associated with lower EREFS (-1.1 ± 1.9 vs -0.47 ± 1.2; P = 0.279) and improved dysphagia scores (0.7 ± 0.5 vs 0.6 ± 0.5; P = 0.490), though these did not reach statistical significance. Conclusion: In this real-world cohort, dupilumab was associated with significantly greater histologic improvement compared to STC in patients with PPI-refractory EoE. Although endoscopic and clinical symptom scores did not show statistically significant differences, observed trends suggest potential clinical benefit. These findings support dupilumab as a promising treatment option for patients with persistent eosinophilic inflammation despite standard therapies. Prospective studies are warranted to confirm these results and assess long-term outcomes.