Increased BMI Associated With Reduced Response to Topical Corticosteroids in EoE

Patients with obesity have approximately 40% odds of endoscopic response to topical corticosteroids.

In eosinophilic esophagitis (EoE), the histologic, symptomatic, and endoscopic responses to topical corticosteroids (tCS) decrease as body mass index (BMI) increases, according to study findings published in Clinical Gastroenterology and Hepatology.

Researchers conducted a retrospective cohort that comprised participants (N=296) who were aged 14 years and older, were treated with a tCS, and underwent follow-up endoscopy with biopsy. Data were obtained from the University of North Carolina (UNC) EoE Clinicopathologic database.

The researchers categorized BMI as underweight (18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2).

A total of 68 participants were classified as having obesity (mean age, 39.4±13.7 years; 57% male), and 228 did not have obesity (mean age, 35.8±15.2 years; 65% male). Patients with obesity had a higher rate of heartburn (59%) vs those who did not have obesity (37%; P =.001), as well as a higher rate of hiatal hernias detected endoscopically (22% vs 11%; P =.02). According to the 4 BMI groups, 9 patients were classified as underweight, 120 were in the normal range, 99 were classified as overweight, and 68 had obesity.

Patients with obesity and EoE had greater peak eosinophil (eos) counts vs patients without obesity (36.1±47.3 vs 21.5 ± 34.2; P =.003). The response was significantly increased in patients without obesity vs patients with obesity at less than 15 eos/high power field (hpf) (61% vs 47%; P =.049) and 6 eos/hpf or fewer (54% vs 38%; P =.02), with a trend for complete normalization at less than 1 eos/hpf (32% vs 22%, P =.10).

In the context of few clinical features that predict response to topical steroids, providers may want to consider BMI in their treatment algorithm and when discussing therapeutic choices with patients.

Patients without obesity with EoE had a significantly greater global endoscopic response than patients with obesity (76% vs 59%, P =.006), as well as a lower post-treatment EoE Endoscopic Reference Score (EREFS) (2.4±1.9 vs 3.2±2.2, P =.01) and endoscopic severity score (ESS) (2.0±1.5 vs 2.4±1.7, P =.05). A global symptomatic response to tCS occurred in 84% of patients without obesity and 67% of patients with obesity (P =.03).

In the 4 BMI categories, patients with obesity had the highest post-treatment eosinophil count in the underweight, normal, and overweight groups, respectively (36.1±47.3 eos/hpf vs 24.5±41.4, 15.9±27.0, and 26.1±35.1; P =.002).

A sequential decrease in the proportion of patients who had a histologic response at the cutoffs of less than 15 (P=.03), 6 or fewer (P = .03), and less than 1 eos/hpf (P =.14) was observed for each increasing BMI category. Endoscopic response was lowest for patients with obesity (59%) vs patients in the underweight, normal, and overweight groups (78%, 82%, and 68%, respectively; P =.007). A higher trend for EREFS and ESS was observed in each increasing BMI category.

Multivariate analysis showed that increasing BMI was independently associated with a reduced histologic response after accounting for age, heartburn, dilation, and hiatal hernia. This finding was observed whether BMI was evaluated as a continuous variable (adjusted odds ratio [aOR] 0.93 for each unit increase in BMI; 95% CI, 0.89-0.98), as nonobese vs obese (aOR 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR 0.46; 95% CI, 0.26-0.84]; obese vs normal [aOR 0.26; 95% CI, 0.13-0.51]).

Study limitations include the retrospective, single-center design and absence of a comparator treatment group. Compliance data for tCS use were also not available and some data were incomplete, including EREFS score and symptom response.

“In the context of few clinical features that predict response to topical steroids, providers may want to consider BMI in their treatment algorithm and when discussing therapeutic choices with patients,” the study authors conclude. “Given that our population was largely proton pump inhibitor (PPI) nonresponders, in newly diagnosed EoE patients with a higher BMI, it may be reasonable to consider combination PPI and tCS treatment, or to select a non–tCS monotherapy regimen such as dietary elimination.”

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

References:

Ketchem CJ, Ocampo AA, Xue Z, et al. Higher body mass index is associated with decreased treatment response to topical steroids in eosinophilic esophagitis. Clin Gastroenterol Hepatol. Published online November 18, 2022. doi: 10.1016/j.cgh.2022.11.004