100406 - Low-dose dupilumab as an effective alternative for eosinophilic esophagitis patients with recurrent esophageal candidiasis

Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated inflammatory disease. While swallowed topical corticosteroids (STCs) are effective, adverse effects such as esophageal candidiasis remains a challenge. In patients who fail conventional therapies or experience intolerance, biologic treatments such as dupilumab (anti–IL-4Rα) represent a promising alternative.

We present the case of a patient with a history of bronchial asthma and allergic rhinitis who developed heartburn and dysphagia to solid foods. Upper endoscopy revealed furrows and microexudates, and biopsies demonstrated 100 eosinophils per high-power field (eos/HPF) in the distal esophagus. The patient underwent sequential treatments: proton pump inhibitors (PPIs), four-food elimination diet, swallowed fluticasone and budesonide orodispersible tablets. Endoscopic evaluations with esophageal biopsies were performed at 3-month intervals to assess histological remission.

The patient was diagnosed with eosinophilic esophagitis but initial treatment with PPIs and a four-food elimination diet failed to achieve histological remission (60 eos/HPF). While swallowed fluticasone induced complete remission (0 eos/HPF), a switch to budesonide orodispersible tablets (1mg/12h) was required due to fluticasone unavailability. This therapy led to recurrent esophageal candidiasis that persisted despite dose reduction to 0.5 mg/day. Due to recurrent fungal infections, treatment with dupilumab 300 mg every 15 days was initiated. After six months of therapy, the patient remained asymptomatic. Follow-up endoscopy with segmental biopsies confirmed sustained histological remission (0 eos/HPF) throughout all esophageal segments, with no evidence of candidiasis. Asthma also remained well controlled during the spring season.

Dupilumab, 300 mg every 15 days, appears to be an effective and safe alternative for patients with EoE who achieve remission with STCs but develop recurrent candidiasis. Personalized biologic strategies may provide dual control of esophageal disease and associated respiratory allergic comorbidities.