From Missed Signals to Meaningful EoE Dialogue: The Impact of Shared Decision-making

Bryan Sauer, MD, MSc, and Rob are paid consultants for Takeda.

Awareness of eosinophilic esophagitis (EoE), a progressive, immune-mediated inflammatory disease of the esophagus, has increased substantially over the past decade, yet challenges in recognition and management remain.^1,2,3 Bryan Sauer, MD, MSc, a gastroenterologist at the University of Virginia Health, notes that while EoE is now more commonly discussed during medical training, early signs of the disease may still be overlooked in routine clinical practice.^2-4

“One of the challenges is that patients do not always describe the symptoms they are experiencing as a problem,” Sauer explains. “They adapt. They chew longer, avoid certain foods or change how they eat, and unless you ask directly, you may not realize a patient has issues with swallowing, or dysphagia.”

For many people living with EoE, these adaptive behaviors can contribute to delayed evaluation and diagnosis.² When inflammation of EoE is uncontrolled, it can progress causing esophageal remodeling and fibrostenotic complications, such as strictures, over time.^2,3 These can lead to increased food impactions that may necessitate urgent endoscopic intervention in some patients.^3,5

Rob, a teacher in Indiana, experienced this firsthand. Before receiving a diagnosis of EoE in his 30s, he managed recurrent episodes of dysphagia by adjusting how he ate.^2,3 This was especially true in social or professional settings, where drawing attention to symptoms felt uncomfortable.⁶

“The food impactions were happening and becoming more frequent,” Rob shares. “I’m not a guy who loves to go to the doctor, but I knew it was time to get this checked out.” His primary care team attributed his symptoms to other causes until Rob advocated to see a specialist.^2,7 “I was given mitigation strategies that did not work. I wish I could have gotten a referral for an endoscopy earlier to see what was going on under the hood.”

Recognizing Symptoms & Closing Diagnostic Gaps

Rob’s experience reflects a broader pattern seen in EoE care. Symptoms often develop gradually and may be mistaken for more common gastrointestinal conditions, including gastroesophageal reflux disease (GERD).^2,8,9 Furthermore, EoE symptoms often start when individuals are young adults, a time when routine medical care may be less consistent.^10,11,12 As a result, opportunities for earlier evaluation and diagnosis may be missed.²

Research shows the average time from symptom onset to diagnosis of EoE can be nearly 3.5 years in children and 8 years in adults.¹³

“I often suggest providers on the frontlines in primary care, pediatrics and internal medicine screen high-risk patients for trouble swallowing, particularly those with allergic conditions including asthma, eczema, allergic rhinitis and food allergies.” While there can be different reasons for dysphagia, Sauer acknowledges that EoE remains underdiagnosed and symptom evaluation is critical.^2,8 Once a diagnosis is made, providers can work together with patients on a treatment plan.

Shared Decision-Making in EoE Management

EoE presents a unique opportunity for shared decision-making, particularly because care often involves ongoing discussion and reassessment rather than a single conversation at diagnosis.^2,14 Sauer explains that early exchanges frequently focus on education, helping patients understand what is happening and why symptoms may change over time.¹⁵

In practice, shared decision-making often means reviewing the available treatment options and discussing what is feasible for the patient, taking into account preferences, tradeoffs and day-to-day routines.¹⁶ As patients gain a clearer understanding of their condition, treatment discussions tend to become more individualized.¹⁵ Sauer emphasizes that these conversations may unfold over multiple visits, giving clinicians and patients time to revisit disease management options as circumstances change.

For health care providers, weighing these options often involves balancing clinical considerations with how a treatment can fit into a patient’s lifestyle and routine. In EoE, goals of treatment often include symptom relief, histologic improvement as assessed by eosinophil counts and improvement in endoscopic appearance.¹

Current evidence-based treatment approaches for EoE inflammation include swallowed topical corticosteroids, dietary elimination, proton pump inhibitors (PPIs) and biologic therapy.¹ Esophageal dilation may be used to address fibrostenotic complications (such as strictures) but does not treat the underlying inflammation.¹

“You want to know what they’ve been dealing with and what feels manageable for them,” he says. “That perspective helps guide the approach and can influence treatment selection.” He adds that patients may not always raise concerns unless they are asked directly.²

“Once I had the results of the biopsy, I started to research different treatment options,” says Rob. “I came prepared to talk about a medication that could fit into my daily life.”

A Treatment Option Designed for EoE

After discussing disease management options and priorities, Rob and his gastroenterologist moved forward with EOHILIA (budesonide oral suspension), the first and only FDA-approved oral medicine designed for EoE.¹⁷

What Is EOHILIA (budesonide oral suspension)?

EOHILIA (budesonide oral suspension) is indicated for 12 weeks of treatment in patients 11 years and older with eosinophilic esophagitis (EoE).

EOHILIA has not been shown to be safe and effective for more than 12 weeks.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

EOHILIA is contraindicated in patients with hypersensitivity to budesonide. Serious hypersensitivity reactions, including anaphylaxis, have occurred with oral budesonide products.

Please see additional Important Safety Information at the end of the article.

Clinical Evidence & Treatment Evaluation

In evaluating options, Rob wanted to understand what taking EOHILIA would involve. EOHILIA, a swallowed form of budesonide designed specifically for the esophagus, is taken orally twice daily for 12 weeks.¹⁷ It comes in premixed 2 mg/10 mL unit-dose packets that do not require measuring or refrigeration.

Due to its streamlined administration, EOHILIA can provide a consistent dose of budesonide when Instructions for Use are followed.¹⁷ His doctor noted EOHILIA has a viscosity that can change. When shaken, it becomes more fluid to ease swallowing and then regains viscosity to flow more slowly through the esophagus.^17,18 For Rob, knowing what to expect from the dosing process helped him visualize how EOHILIA could fit into his routine.

Rob’s gastroenterologist also reviewed the clinical evidence of each treatment option.

Histological remission and dysphagia symptom responses with EOHILIA were studied in two placebo-controlled 12-week clinical trials of 410 patients (ages 11 to 56) with EoE.¹⁷ Results demonstrated that 52.4% (Study 1) and 35.8% (Study 2) of patients achieved histological remission with EOHILIA versus placebo after 12 weeks. Additionally, patients experienced a greater reduction with EOHILIA versus placebo, -3.7 (Study 1) and -8.6 (Study 2), in absolute change from baseline in the Dysphagia Symptom Questionnaire (DSQ) after 12 weeks.

Evidence-based guidelines from the American College of Gastroenterology (ACG) on diagnosis and management of EoE have given EOHILIA, as part of a group of medications called swallowed topical corticosteroids, a strong recommendation as a first-line treatment option for EoE.¹ This is based on a moderate level of clinical trial data using GRADE methodology, a formal process used to evaluate how strong the evidence is and how confident health care providers can be in recommending a medication for use in clinical care.

As with other treatment options in EoE, Rob’s care team emphasized the importance of follow-up and reassessment, including monitoring symptoms and potential adverse effects. The most common adverse reactions with EOHILIA in clinical trials (≥2%) included respiratory tract infection, gastrointestinal mucosal candidiasis, headache, gastroenteritis, throat irritation, adrenal suppression and erosive esophagitis.¹⁷

Supporting Access, Navigation & Care Coordination

Sauer emphasizes the importance of selecting a treatment that is supported by evidence and aligned with what patients can realistically maintain.¹⁵

“I am on the patient’s side,” said Sauer. “I want to celebrate their successes (including improvements in symptoms and biopsy findings), but I also want to know how often they’re missing doses or if they’re having challenges with accessing their medication.” He explains that his nurse coordinator and other members of the care team are very involved in navigating the system and supporting continuity of care over time.

EOHILIA, like many other prescription medications, may require coverage authorization from a patient’s health insurance company. Takeda, the manufacturer of EOHILIA, offers patient access support to assist patients on their treatment journey.

For Rob, having ongoing communication with his care team helped set expectations after EOHILIA was prescribed. He describes the value of knowing who to contact with questions and having support beyond the exam room.

Navigating Care in EoE

Today, Rob says his life feels markedly different than when difficulty swallowing and food impactions were a frequent part of his daily life.¹⁹ Reflecting on the improvement in dysphagia symptoms, he notes that meals feel easier to navigate, especially in social and professional settings.

As awareness of EoE continues to grow and the management landscape continues to evolve, earlier recognition and collaborative decision-making are helping improve outcomes.¹⁵

For health care providers, understanding patient experiences while applying evidence-based care can support more effective and individualized management.¹⁵ In Sauer’s experience, EoE care often comes down to paying attention to what changes between visits, which can signal when something needs to be revisited.²⁰

He notes that these touchpoints do not need to be complicated. Asking patients how eating has been going or whether anything feels different than before can surface details that are not always raised on their own.² Additionally, discussing adaptive behaviors around eating can identify individuals who continue to be symptomatic.

For Rob, follow-up visits made it possible to talk about those changes rather than continuing to work around them. Returning to those conversations helped ensure that next steps were based on what he was actually experiencing.

Taken together, this reinforces a simple point for providers navigating EoE management with their patients: asking open-ended questions at the right time can meaningfully shape care decisions.²⁰

IMPORTANT SAFETY INFORMATION (continued)

Hypercorticism and Adrenal Axis Suppression

Monitor patients for signs and symptoms and consider reducing the EOHILIA dosage. Use is not recommended in severe hepatic impairment (Child-Pugh Class C). Monitor for hypercorticism in moderate hepatic impairment (Child-Pugh Class B). Where patients are subject to stress situations (e.g., trauma, surgery, infection) supplementation with a systemic corticosteroid is recommended.

Immunosuppression and Increased Risk of Infection

Corticosteroid-associated infections can be mild, severe, and at times fatal. Monitor patients and consider discontinuation if infection develops.

• Tuberculosis and Hepatitis B Virus (HBV) reactivation may occur. Closely monitor EOHILIA patients. Screen for HBV.
• Varicella Zoster (VZ) and Measles can be serious or fatal. Avoid exposure. If a patient is exposed to varicella, consider prophylaxis with VZ immune globulin (IG); if varicella develops, consider antiviral treatment. If a patient is exposed to measles, consider prophylaxis with IG.
• Rule out amebiasis before starting EOHILIA in patients who were in the tropics or have unexplained diarrhea.
• Avoid EOHILIA in patients with: systemic fungal infections, known or suspected Strongyloides infection, cerebral malaria, and active ocular herpes simplex.
• Localized Infections: In clinical trials, some patients developed Candida albicans infections in the mouth, throat, and esophagus. Instruct patients: do not eat or drink for 30 minutes after taking EOHILIA; after 30 minutes rinse mouth with water and spit without swallowing. Treat candidiasis infections with appropriate antifungal therapy and consider discontinuing EOHILIA.

Erosive Esophagitis

Patients who experienced erosive esophagitis in clinical trials did not have erosions at baseline and most were receiving a proton pump inhibitor. Advise patients or caregivers to report new onset or worsening of erosive esophagitis to their healthcare provider. Consider endoscopic evaluation.

Symptoms of Steroid Withdrawal in Patients Transferred from Other Systemic Corticosteroids

Adrenocortical function monitoring may be required in patients who are transferred from high systemic effects corticosteroids to EOHILIA, since symptoms attributed to withdrawal of steroid therapy, including those of acute adrenal axis suppression or benign intracranial hypertension, may develop.

Taper slowly from high systemic effects corticosteroids. Replacing systemic corticosteroids with EOHILIA may unmask previously controlled allergies (e.g., rhinitis and eczema).

Other Corticosteroid Effects

Monitor patients with or family history of: hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma, or cataracts or with other conditions where corticosteroids may have unwanted effects.

Additional Established Class Effects of Corticosteroids not seen in EOHILIA 12-week clinical trials. The maximum recommended duration of treatment with EOHILIA is 12 weeks:

• Effect on Growth: Use of corticosteroids may cause a reduction of growth velocity. Monitor the growth of pediatric patients on EOHILIA.
• Kaposi’s Sarcoma: Reported to occur with corticosteroids, most often for chronic conditions. Discontinuation of corticosteroids may result in clinical improvement of Kaposi’s sarcoma.

ADVERSE REACTIONS

Most common adverse reactions (≥2%) are: respiratory tract infection (13%), gastrointestinal mucosal candidiasis (8%), headache (5%), gastroenteritis (3%), throat irritation (3%), adrenal suppression (2%), and erosive esophagitis (2%).

DRUG INTERACTIONS

Avoid concomitant use with CYP3A4 inhibitors (including grapefruit juice), which can increase systemic budesonide concentrations.

USE IN SPECIFIC POPULATIONS

• Pregnancy: Hypoadrenalism may occur in infants whose mothers received corticosteroids during pregnancy. Carefully observe infants for hypoadrenalism and manage accordingly.
• Lactation: Lactation studies have not been conducted. Consider the benefits of breastfeeding, the mother’s need for EOHILIA, and any potential adverse effects on the infant from EOHILIA, or from the underlying maternal condition.
• Hepatic Impairment: Not recommended in severe hepatic impairment (Child-Pugh Class C). Monitor for hypercorticism in moderate hepatic impairment (Child-Pugh Class B).

Please click here for full Prescribing Information.

This content is sponsored by Takeda. Bryan Sauer, MD and Rob are paid consultants for Takeda. Individual experiences with eosinophilic esophagitis (EoE) may vary. The information in this article is for educational purposes only and is not medical advice. Always consult a health care professional for medical advice, diagnosis or treatment.

©2026 Takeda Pharmaceuticals U.S.A., Inc. All rights reserved. TAKEDA and the TAKEDA logo are registered trademarks of Takeda Pharmaceutical Company Limited. EOHILIA and the EOHILIA logo are trademarks of ViroPharma Biologics LLC. US-BOS-0570v1.0 05/26

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