Treatment of eosinophilic esophagitis with immune modulating agents

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory and an immune-mediated condition diagnosed based on both clinical and pathologic findings. EoE has been identified as one of the leading causes of esophageal dysfunction worldwide. If untreated, EoE often follows a progressive course that leads to fibrosis and esophageal stricture and perforation. The use of biologic therapies that target specific pathways will help us understand the essential pathophysiologic steps in EoE, in addition to providing symptomatic treatment. In this narrative review, we review the potential targeted therapies of these cells and related pathways, the evidence of therapeutic benefit, and suggestions for future therapeutic approaches. An updated review of treatment options is necessary given deeper understanding of the pathogenesis and more recent advances in treatment since the consensus recommendations published in 2016. Objective: We sought to review the contemporary data with regard to treatment approaches in EoE, particularly through immune-modulating therapeutic approaches. Methods: The MEDLINE (PubMed) data base was queried by using specified search terms. Articles were selected based on their contribution to the understanding of how therapeutics for EoE, particularly those that modulate immunity play a role in the management of this disease. Results: Among immune-modulating therapies for EoE, anti-interleukin (IL) 5/IL-5 Receptor (R) α and anti-IL-13/IL-4 Receptor (R) α therapies have the most accumulated clinical trial and safety data at this time. Other emerging immunologic targets that warrant discussion include thymic stromal lymphopoietin and Sialic acid-binding IG-like lectin 8 (Siglec-8). Furthermore, the contribution of fibroblasts and myofibroblasts to the pathogenesis of EoE also provides many potential therapeutic targets. Allergen-specific immunotherapies have shown variable benefit in the treatment of EoE. Conclusion: Immune-modulating therapies seem to be a promising avenue of the treatment of EoE; both established and emerging targets of therapy exist to manage this condition.