Commentary
Article
The Pharmacist’s Role in Eosinophilic Esophagitis Treatment, Navigating Eohilia, and Improving Patient Outcomes
Author(s):
Although dietary changes have historically been a key approach to managing eosinophilic esophagitis, their limitations highlight the need for pharmacologic treatments.
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition characterized by inflammation of the esophagus, leading to symptoms such as dysphagia, food impaction, and chest pain. Historically, treatment options for EoE have been limited, often relying on proton pump inhibitors (PPIs), dietary modifications, and off-label use of medications such as corticosteroids.1 However, the recent approval of budesonide oral suspension (Eohilia; Takeda) marks a significant advancement in EoE management. Pharmacists play a critical role in helping patients navigate this new treatment, ensuring they understand its benefits, potential adverse effects (AEs), and access pathways.
Pharmacists play a critical role in helping patients navigate this new treatment | Image credit: Matthieu | stock.adobe.com
Historic EoE Treatments
Eohilia is the first FDA-approved medication specifically designed for the treatment of EoE. It is an oral suspension of budesonide, a corticosteroid that targets inflammation locally in the esophagus. Unlike systemic corticosteroids, budesonide minimizes systemic absorption, reducing the risk of widespread AEs.2 This targeted approach represents a major improvement over historic treatments, which often lacked specificity and efficacy.
Historic treatments consisted of PPIs, primarily for their acid-suppressing effects. However, they are not effective for all patients, particularly those with non–acid-related inflammation.3 Budesonide addresses the underlying inflammation directly, offering a more targeted solution.
Similarly, clinicians have historically prescribed off-label topical corticosteroids such as fluticasone or budesonide slurry to reduce esophageal inflammation. Although effective, these formulations were not standardized, leading to variability in dosing and administration.3 As a consistent, FDA-approved formulation, budesonide oral suspension can improve patient adherence and outcomes.
Finally, patients were often advised to try elimination diets, which remove likely food triggers to improve symptoms. Then, possible triggers are added back into the patient’s diet in a specific order to identify which worsen the EoE. The 2-food elimination diet is the most common and has replaced the previously used 6-food elimination diet.4
For this treatment, patients remove the top 2 most common food allergens (all milk products, wheat, and/or gluten) from their diet for 8 to 10 weeks. An esophagogastroduodenoscopy (EGD) is then performed with a biopsy to retest the esophagus for narrowing or inflammation. If the patient is found to be in remission, they can reintroduce the foods one at a time, with an EGD test after each challenge. Research has also shown that a single food elimination (milk products) may be the only elimination needed.4
Although dietary changes and EGD testing can be effective for some patients, they come with significant challenges and limitations. The complexity of adhering to elimination diets often causes reduced quality of life and heightened stress for patients, as well as potential nutritional deficiencies. Even when dietary changes are successful, they may not fully resolve esophageal inflammation. Persistent inflammation can lead to long-term complications, such as esophageal strictures and fibrosis, highlighting the need for additional treatment options.4
The Role of Pharmacologic Treatments
Given the limitations of dietary changes, pharmacologic treatments such as budesonide oral suspension offer a more reliable and standardized approach to managing EoE. The suspension directly targets esophageal inflammation, providing a consistent and measurable response in most patients. Unlike dietary modifications, which require significant lifestyle adjustments, budesonide oral suspension is a more convenient, FDA-approved medication that can be integrated into a patient’s daily routine with minimal disruption.2
Additionally, pharmacologic treatments can be used in conjunction with dietary changes for patients who benefit from both approaches. This combination therapy allows for a more personalized and comprehensive treatment plan, addressing both the inflammatory component of EoE and any food triggers that may contribute to the disease.
The Pharmacist’s Role
Pharmacists are uniquely positioned to educate patients about EoE and budesonide oral suspension, ensuring they understand its benefits, proper use, and potential AEs. Budesonide oral suspension is taken twice daily for 12 weeks, and patients should be instructed to swallow the medication rather than inhale it. Pharmacists can demonstrate proper administration techniques to ensure optimal delivery to the esophagus.
Although budesonide oral suspension is designed to minimize systemic absorption, patients should be informed about potential AEs such as oral thrush, headache, and gastrointestinal discomfort. Pharmacists can advise on strategies to mitigate these challenges, such as rinsing the mouth after administration to reduce the risk of thrust.
Access to new medications can be challenging for patients and is a prime area for pharmacists to get involved. Pharmacists can assist patients in navigating insurance coverage, prior authorization requirements, and patient assistance programs. By collaborating with prescribers and insurance companies, pharmacists can help ensure patients receive timely access to budesonide oral suspension.
Conclusion
The introduction of budesonide oral suspension represents a significant milestone in the treatment of EoE, offering a targeted, FDA-approved option for patients. Pharmacists play a vital role in this new treatment landscape, providing patient education, facilitating access, and ensuring safe and effective use. By leveraging their expertise, pharmacists can help improve outcomes for patients with EoE, empowering them to manage their condition more effectively.
