Eosinophilic oesophagitis (EoE) is a chronic immune-mediated oesophageal disease requiring long-term anti-inflammatory therapy [1]. Budesonide orodispersible tablets (BOT) are licensed for induction and maintenance treatment [2], although real-world induction outcomes are more variable. The population-based DanEoE cohort reported 48% histological, 57% clinical and 39% combined remission after induction [3], illustrating the challenge of achieving stable disease control outside trial conditions. In the UK, maintenance prescribing policies vary geographically, leading many patients to choose a once-daily 1 mg regimen after induction to avoid treatment breaks. However, evidence for the effectiveness of this regimen is limited.

This study aims to evaluate the real-world effectiveness of once-daily orodispersible budesonide 1 mg as maintenance therapy in adult EoE patients.

We conducted a single-centre prospective observational cohort study, over 25 months (Oct 2023–Nov 2025), of adults with confirmed EoE who achieved histological remission <15 eosinophils / high powered field (phpf) following induction BOT, and chose to take 1 mg once-daily maintenance. Disease activity was assessed using endoscopy and/or capsule sponge test (Endosign) with EREFS scoring, histology (peak eosinophil count phpf). Symptoms were documented using the Dysphagia Symptom Questionnaire (DSQ) and direct symptom enquiry. Primary endpoints were histological and clinico-histological remission. Secondary endpoints included DSQ outcomes and phenotype-based comparisons.

30 patients commenced once-daily 1 mg maintenance therapy (median age 46 years, IQR 32–58; 57% male). The median duration of maintenance treatment before reassessment was 17.9 weeks (IQR 12.3–35.6).

Of these, 29/30 (96.7%) patients underwent gastroscopy, and 20/30 (66.7%) had same-day capsule sponge sampling; 1/30 (3.3%) had capsule sponge only. Using the highest peak eosinophil count across gastroscopy and capsule sponge, 25/30 (83.3%) were in histological remission and 5/30 (16.7%) had active inflammation. Clinical remission occurred in 26/30 (86.7%) patients. Clinical remission occurred in 26/30 (86.7%). DSQ scores were available for 23/30 (76.7%), of whom 14/23 (60.9%) had a DSQ score of 0. Clinico-histological remission occurred in 23/30 (76.7%).

Among the 29 gastroscopy patients, 16/29 (55.2%) had fibrostenotic disease and 12/29 (41.4%) had inflammatory-only disease. Histological remission occurred in 13/16 (81.3%) fibrostenotic patients vs 11/12 (91.7%) inflammatory patients (Fisher p=0.61). Clinical remission occurred in 13/16 (81.3%) vs 11/12 (91.7%) (p=0.61). Clinico-histological remission occurred in 11/16 (68.8%) vs 10/12 (83.3%) (p=0.66). Median treatment duration did not differ significantly between phenotypes (p=0.35).

In this real-world cohort once-daily 1mg BOT maintained remission with similar or better efficacy to reported series using twice daily dosing.  These findings support dose de-escalation after induction therapy to a once daily 1mg regime which may be easier to implement. They also demonstrate the previously reported use of capsule sponge sampling in monitoring EoE. Larger studies with extended follow-up are needed to confirm these findings but this study supports current pragmatic clinical practice. Additionally, once daily treatment may also improve compliance and be more financially acceptable.