Patient Preferences for Medical Treatment of Eosinophilic Esophagitis

Introduction: Eosinophilic esophagitis (EoE) is chronic allergic inflammatory condition associated with esophageal dysfunction. Several medical treatment options exist, including proton pump inhibitors (PPIs), swallowed topical steroids (STS), and biologic therapy, which vary by efficacy, side effects, and other attributes. Patients must balance these tradeoffs when selecting treatments and knowledge of these preferences is limited. We aimed to quantify patient preferences for medical management of EoE. Methods: Patients ≥18 years with a confirmed or self-reported diagnosis of EoE, identified through disease-specific diagnostic codes or by membership in a patient advocacy organization, completed an online survey eliciting EoE-specific treatment preferences and clinicodemographic information. A discrete choice experiment (DCE) was constructed to quantify the importance of 4 treatment attributes: time without symptoms (10, 5 or 2 months), chance of no inflammation defined by histologic remission with < 15 eosinophils/hpf at 12 months (90, 60, or 40%), regulatory approval for EoE, and treatment type (PPI, STS, or biologic therapy). Respondents completed 9 experimentally designed DCE questions. Data were analyzed with a random-parameters logit model to elicit relative preference weights (PW) for each treatment attribute. Results: 212 respondents completed the survey (56% female; 93% White) with a mean age of 47 years and 56% reported EoE symptoms within the prior 2 weeks (Table 1). Patients preferred treatments offering a higher chance of no inflammation at 12 months (90% PW 100; 60% PW 43.8) and more time without symptoms (10 months PW 58.2; 5 months PW 31.2) (Figure 1). Patients also valued a treatment with regulatory approval specifically for EoE (PW 13.3) over one approved for other conditions. There was no significant difference in preferences for biologic therapy (PW 17.6) or STS (PW 11.0), though both were preferred to PPIs. Overall, a 90% chance of no inflammation was 1.7, 5.7 and 7.5 times more important than 10 months without symptoms, treatment type, and having FDA approval for EoE, respectively. Conclusion: Patients with EoE have increasing options for medical therapy and prefer a treatment offering higher chances of mucosal healing over symptom resolution. Regulatory approval for EoE is also preferred. These findings have important implications for shared clinical decision making regarding medical management and future regulatory considerations for drug approval. Table 1. - Patient Demographics and Eosinophilic Esophagitis (EoE) Clinical History Patient Demographics (N = 212) Statistic N (%) Age in years (Mean, SD) 46.6, 14.5 Gender, Female 118 (55.7%) Race*^ White 198 (93.4%) Black, African American, Asian, American Indian or Alaskan Native 12 (5.7%) Prefer not to say 3 (1.4%) Ethnicity* Hispanic, Latino, or Spanish origin 6 (2.8%) Not Hispanic, Latino, or Spanish origin 198 (93.4%) Prefer not to say 4 (1.9%) Education* Less than a 4-year college degree 54 (25.5%) 4-year college degree or more 154 (72.6%) Health Insurance*^ State or federal insurance exchange 13 (6.1%) Employer or union 161 (75.9%) Medicare 31 (14.6%) Medicaid 8 (3.8%) Veterans Affairs 6 (2.8%) Other 7 (3.3%) No insurance 1 (0.5%) Household Income Less than $50,000 34 (16.0%) $50,001 to $99,999 36 (17.0%) $100,000 or more 110 (51.9%) Do not know 2 (0.9%) Prefer not to say 26 (12.3%) Disease Experience and Treatment History Time since diagnosis of EoE Less than 1 year 24 (11.3%) 1-5 years 97 (45.8%) >5 years 91 (42.9%) Symptomatic within last 2 weeks 119 (56.1%) Number of prior endoscopies* 1 34 (16.0%) 2-3 77(36.3%) 4 or more 93(43.9%) Don't know/Not sure 4(1.9%) Previous Dilation No 93(43.9%) Yes 115 (54.3%) Don't know/Not sure 4(1.9%) Number of Dilations No prior dilation 93(43.9%) 1-2 prior dilations 66 (31.1%) 3 or more prior dilations 42(19.8%) Don't know/Not sure 11 (5.2%) Experience with proton pump inhibitors (PPIs) Never taken PPI 17 (8.0%) Currently takes PPI 101 (47.6%) Previously took PPI 94 (44.3%) Experience with swallowed topical steroids, ever used Syrup or slurry 54 (25.5%) Inhaler 86 (40.6%) Experience with dietary restrictions No prior restrictive diet 69 (32.5%) Yes, due to foods that trigger eosinophilic esophagitis (EoE) 102(48.1%) Yes, due to diagnosed food allergies (anaphylaxis) 83 (39.2%) *Missing, N = 4. ^Respondents can select multiple choices for both insurance and race therefore may not equal 100%. Figure 1.: Patient preference weights for medical therapy of eosinophilic esophagitis (EoE) with 95% confidence intervals.