Treatment Patterns in Patients With Eosinophilic Oesophagitis Referred for Expert Consultation

BACKGROUND & AIMS: Eosinophilic esophagitis (EoE) patients deemed treatment-refractory are frequently referred to tertiary centres. We aimed to characterize expert perspectives on patients referred for refractory EoE, including its causes, prevalence, and evaluation. METHODS: We conducted an anonymous and blinded cross-sectional survey of international EoE experts (n = 52) assessing provider characteristics, referral patterns, perceived causes of treatment failure, diagnostic approaches, and prior therapies. Descriptive statistics and subgroup analyses were performed. RESULTS: Respondents were predominantly gastroenterologists (77%) and practiced in academic settings (87%) with high EoE volume. Experts estimated that true refractoriness to medical and diet therapy was 15% [IQR 10-25], median 31% [20-50], respectively. Patients referred for perceived refractory EoE had been treated with PPIs (80%), topical steroids (55%), and elimination diets (45%); dupilumab (10%) was infrequently trialled. Half of the patients referred had been on combination therapy. After referral, experts focused on assessing medication adherence (98%), dosing (92%), and administration technique (90%), with most repeating endoscopy (85%) and performing oesophageal dilation (42%). The causes of perceived refractory disease were subtherapeutic dosing (34%), incorrect medication administration (30.5%), inappropriate medication choice (26.5%), and dietary non-adherence (26%). Functional and behavioural contributors including co-existing oesophageal hypersensitivity (20%), ARFID (9%), and rumination syndrome (5%) were also reported. Experience in treating EoE patients assessed by less than or greater than 10 years did not affect most results. CONCLUSIONS: Among international experts, most referred EoE patients labelled as refractory had received suboptimal medical and dilation therapy. This highlights opportunities to optimize care along guideline recommendations prior to referral.