Methods of treating eosinophilic esophagitis and depleting mast cell

Abstract

Disclosed herein are methods of reducing mast cell count that results in mucosal normalization. The present disclose also provides methods of treating eosinophilic oesophagitis that result in a reduced mast cell count and improved symptom scores. Dosages, formulations, and methods for administration of corticosteroids are provided.

Description

METHODS OF TREATING EOSINOPHILIC ESOPHAGITIS AND DEPLETING MAST CELLCROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of and priority to U.S. Provisional Application No. 63 / 609,565, filed December 13, 2023; and U.S. Provisional Application No. 63 / 561,663, filed March 5, 2024, the contents of each of which are hereby incorporated by reference in their entirety for all purposes.BACKGROUND

[0002] Eosinophilic oesophagitis (EoE) is a chronic destructive immune-mediated inflammatory disease of the oesophagus, characterized clinically by oesophageal dysfunction and histologically by eosinophilic infiltration. Patients with EoE present with symptoms of difficulty swallowing (dysphagia), chest pain, persistent heartburn, upper abdominal pain, and food getting stuck in the esophagus after swallowing (impaction). The current treatments for EoE include dietary modifications, proton pump inhibitors, and corticosteroids.

[0003] Clinical outcomes often do not correlate to efficacy. For example, eosinophil levels traditionally have been used to determine whether a treatment for EoE was effective. However, a reduction in eosinophil levels did not necessarily correlate to efficacy, as some subjects with a significant reduction in eosinophils still experienced dysphagia and other symptoms of EoE, and some subjects experiencing a reduction in dysphagia episodes and / or severity had high levels of eosinophils. There exists a need in the art for methods of identifying effective treatments for EoE, the appropriate clinical outcomes, and effectively treating EoE by targeting mast cells to improve mucosal healing. The present disclosure addresses these needs.SUMMARY OF THE INVENTION

[0004] In embodiments, the disclosure provides a method of reducing mast cell count in a subject in need thereof, comprising topically administering a corticosteroid to the subject’s esophageal tissue, wherein after administering the corticosteroid, the subject has a peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus. Inembodiments, the methods disclosed herein comprise, before topically administering the corticosteroid to the subject’s esophageal tissue, obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count. In embodiments, the methods disclosed herein comprise, after topically administering the corticosteroid to the subject’s esophageal tissue for a period of time (e.g., at least 12 weeks or at least 24 weeks), obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count.

[0005] In embodiments, the disclosure provides a method of treating eosinophilic esophagitis (EoE) in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 12 weeks, wherein the subject has a peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus.

[0006] In embodiments, the disclosure provides a method of treating eosinophilic esophagitis (EoE) in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 24 weeks, wherein the treatment leads to a reduction in a peak post-treatment mast cell count per HPF in at least one biopsy of the esophagus of the subject by at least about 60% at week 24 compared to baseline.

[0007] In embodiments, the disclosure provides a method of optimizing therapy in a subject having eosinophilic esophagitis (EoE) and receiving treatment of a corticosteroid comprising: (a) topically administering about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid to the subject’s esophageal tissue, once daily for a treatment period; (b) determining at several points in time a level of at least one mast cell-associated biomarker present in a sample from the subject, wherein the sample is selected from the group consisting of a biopsy of the esophagus, a serum sample, a blood sample, and a urine sample, wherein the biomarker is indicative of the severity of EoE in the subject; and (c) adjusting the treatment period based on the level of the at least one mast cell associated biomarker.

[0008] In embodiments, the disclosure provides a method of achieving an EREF responder, comprising topically administering a corticosteroid to the subject’s esophageal tissue, wherein the EREF responder is defined as total score between 0 and 2, inclusive, with no score for any component (edema, exudates, furrows, rings, and strictures) greater than 1 and no worsening from baseline in any component.

[0009] In embodiments, the disclosure provides a method of achieving zero episodes of dysphagia over 14 consecutive days in a subject, comprising topically administering a corticosteroid to the subject’s esophageal tissue.

[0010] Other aspects and embodiments will be apparent to one skilled in the art in light of the detailed description and illustrative Examples that follow.BRIEF DESCRIPTION OF THE FIGURES

[0011] FIG. 1 depicts a schematic overview of the Phase III: SP-1011-003 corticosteroid studies.

[0012] FIG. 2 depicts a schematic overview of a second Phase III: SP-1011-003 corticosteroid studies described in Example 4.DETAILED DESCRIPTION

[0013] Disclosed herein are methods of reducing mast cell count that results in mucosal normalization (i.e., complete mucosal healing). The present disclose also provides methods of treating EoE that result in a reduced mast cell count and improved symptom scores. In embodiments, the methods comprise administering 3 mg fluticasone propionate once-daily for at least 12 weeks that results in a peak mast cell count of no more than 6 mast cell per HPF, mucosal normalization and / or improved symptom scores.Definitions

[0014] As used herein, and in the appended claims, the singular forms “a”, “an”, and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a protein” can refer to one corticosteroid or to mixtures of corticosteroid, and reference to “the method” includes reference to equivalent steps and / or methods known to those skilled in the art, and so forth.

[0015] As used herein, the term “about” or “approximately” when preceding a numerical value indicates the value plus or minus an acceptable degree of variation in the art. In embodiments, “about” indicates the value plus or minus a range of 10%. For example, “about 100” encompasses 90 and 110.

[0016] The terms “treat,” “treatment,” and “treating,” as used herein, refer to an approach for obtaining beneficial or desired results, for example, clinical results. For the purposes of this disclosure, beneficial or desired results may include inhibiting or suppressing the initiation orprogression of EoE; ameliorating, or reducing the development of or symptoms of EoE; or a combination thereof.

[0017] A “histologic responder” may be defined as a subject who achieves a histologic response of peak eosinophils / HPF number of no more than 6 (as primary determinant). HPF may be defined as a standard area of 0.237 square millimeters in a microscope with 40x lens and 22mm ocular.

[0018] A “histologic non-responder” may be defined as a subject who does not have a histologic response (i.e., do not achieve a histologic response of peak eosinophils / HPF number of no more than 6).

[0019] ‘ ‘Post-treatment” as used herein refers to a point in time after the corticosteroid has been administered for consecutive days and an outcome is measured. “Post-treatment” does not denote or require that treatment has been terminated. Instead, treatment typically continues after measuring the outcome. For example, mast cells may be measured after 12 weeks of treatment, and this is referred to as “post-treatment” mast cell count, and the subject may continue treatment after week 12.Eosinophilic Esophagitis (EoE}

[0020] In embodiments, the methods of the present disclosure are utilized to treat EoE. EoE has been described in children and adults with dysphagia and other oesophageal symptoms either alone (typical presentation) or as a manifestation of eosinophilic gastroenteritis (unusual presentation). In its isolated form, the disease exhibits symptoms and histologies similar to gastroesophageal reflux disease (GERD) (e.g., dysphagia, food impaction, nausea, vomiting, and weight loss) and due to this in its first appearance in the 1960’s EoE was originally diagnosed as GERD (Furuta et al. 2007). Over time, the similarities were questioned as EoE subjects did not experience reflux and did not typically respond to anti-reflux therapy, and it was thereafter considered as a separate clinical entity.

[0021] In embodiments, EoE is defined as a primary clinicopathologic disorder of the oesophagus, which is characterised by oesophageal and / or upper gastrointestinal (GI) tract symptoms in association with oesophageal mucosal biopsy specimens containing > 15 intraepithelial eosinophils (EOS) / high power field (HPF) in one or more biopsy specimens and absence of pathologic GERD as evidenced by a normal pH monitoring study of the distal oesophagus or lack of response to high-dose proton pump inhibitor (PPI) medication.

[0022] In embodiment, the methods of the present disclosure are utilized to heal or normalize mucosa in subjects with EoE. In embodiment, mucosal normalization (i.e., complete mucosal healing) refers to absence of one or more features selected from eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis. In embodiments, eosinophilic microabscesses are small localized collection of eosinophiles in the esophagus. In embodiments, degranulation is the process that active eosinophils release their granular contents into the surrounding tissues. The granules contain proteins that can damage the tissue and contribute to the symptoms of EoE. Degranulation is a sign of active eosinophil inflammation. In embodiments, spongiosis refers to the presence of intercellular edema in the squamous epithelium of the esophagus. In embodiments, basal zone hyperplasia refers to an expansion of the basal layer of the epithelium, and it can occupy more than 15% of the total thickness. The presence of basal zone hyperplasia is indicative of chronic inflammation. In embodiments, esophageal fibrosis refers to deposition of fibrous tissue in the esophagus. This leads to stiffening of the esophageal wall and can contribute to symptoms like food impaction and dysphagia.

[0023] EoE affects all ages and ethnic backgrounds. EoE is predominant in non-Hispanic whites. The majority of affected subjects with EoE are male, who usually present with EoE symptoms during childhood or in their 30’s or 40’s. EoE in children usually presents between the ages of 5 and 10 years old and 70% of childhood EoE persists into adulthood. Clinical manifestations of EoE may vary with age with a difference in symptoms between infants and young children compared to adolescents and adults. In contrast to younger children, older children typically present with either heartburn or symptoms of dysphagia. Adolescents present with an oesophageal food impaction. Subjects with an atopic background or food-allergies have been shown to present with more severe oesophageal symptoms and food impaction. In embodiments, common symptoms of EoE during adolescence are GERD-like symptoms. In embodiments, children aged 11 years and older mostly report dysphagia and food impactions, which are also the most common indications for endoscopy in adult subjects.

[0024] In embodiments, EoE subjects may be diagnosed using any appropriate measures in the art. In embodiments, the subject is diagnosed with EoE based on symptoms, score in the assessment using a subject reported outcome (PRO) questionnaire, histology, and / or failed documentation on proton pump inhibitors. In embodiments, the subject received proton-pump inhibitor (PPI) therapy prior to administration of a corticosteroid. In embodiments, the subjectfailed to improve after 8 weeks of high-dose (e.g. 40 mg) PPI. A lack of response to PPI therapy may be defined as Peak eosinophil count > 15 / HPF in at least one biopsied location after 8 weeks of treatment with a high dose PPI. In embodiments, the failure of PPI therapy is documented before administration of a pharmaceutical composition of the present disclosure. In embodiments, the subject did not receive PPI therapy prior to administration of a corticosteroid.

[0025] The cause of EoE is unknown but it is believed to be caused by an abnormal immune response to environmental allergens, including food. There also appears to be a genetic component that predisposes certain subjects to the condition.

[0026] In embodiments, the methods of the disclosure utilize corticosteroids (e.g. fluticasone propionate or budesonide) for the treatment of EoE. Conventionally, steroid treatment required repurposing formulations intended for inhalers in order to orally administer corticosteroids (e.g. spraying the medication into the mouth and swallowing, or emptying the contents intended for nebulization into a liquid preparation or suspension). However, these inhaled formulations and liquid preparations had many drawbacks, including poor patient compliance and high rates of fungal infections, including oral, oropharyngeal, and esophageal candidiasis.

[0027] In embodiments, the methods of the disclosure provide administration of a corticosteroid that is formulated as a solid composition. In embodiments, the solid composition is in the form of a gel, lozenge, lollipop, effervescent tablet, powder, granules, an orally disintegrating composition or an orally dispersing composition. In embodiments, the orally disintegrating composition is a tablet, wafer, film, effervescent, or lyophilized matrix. In embodiments, an orodispersible tablet of budesonide is used for the treatment of EoE. In embodiments, an orodispersible (or orally disintegrating) tablet of fluticasone (or any other corticosteroid) is used for the treatment of EoE.

[0028] While solid compositions improve patient compliance, current dosing methods still present a risk of infections. The most common infections associated with long term corticosteroid use in EoE subjects are fungal infections, including oral, oropharyngeal, and oesophageal candidiasis. For example, JORVEZA® is an orodispersible tablet containing 1 mg of budesonide, and is approved in Europe for twice daily dosing to treat EoE (i.e., the total daily dose is 2 mg). However, the candidiasis infection rate associated with JORVEZA® is high. 16.9% of subjects experience esophageal candidiasis, 3.4% of subjects experience oral candidiasis, and 5.1% of subjects experience oropharyngeal candidiasis. Fungal infections present symptoms that are similar to EoE, such as difficulty and discomfort in swallowing. Thus, even though the corticosteroid therapyis effective in reducing esophageal inflammation, subjects treated with JORVEZA® (or other corticosteroids) may still believe they are experiencing EoE.

[0029] The present inventors surprisingly and unexpectedly found that once daily administration of a corticosteroid is more effective to treat EoE and improve EoE symptoms than twice daily administration, even when the total daily dose for the once daily administration is the same as the total daily dose for twice daily administration. Not only is once daily administration of a corticosteroid effective to treat EoE (e.g., by reducing eosinophils), but once daily administration significantly reduces the risk of candidiasis compared to twice daily administration. As such, subjects administered the corticosteroid once daily have surprisingly improved symptom outcomes compared to subjects receiving twice daily administration.Mast Cells in Eosinophilic Esophagitis

[0030] Applicant has observed that increased mast cell counts and mast cell activation (MCA) is associated with persistent mucosal abnormalities and symptoms in subjects with EoE. Mast cells likely contribute to epithelial barrier dysfunction, smooth muscle hypertrophy and contraction, and subepithelial fibrosis. Thus, mast cells appear to play a key role in EoE pathogenesis. There exists a need in the art for methods of effectively treating EoE by targeting mast cells to improve mucosal healing. The present disclosure addresses these needs.

[0031] In embodiments, the methods of the present disclosure are utilized to reduce mast cell (MC) count. Increased numbers of mast cells are seen in esophageal tissue samples from subjects with EoE, and degranulation is common (Strasser et al., Histopathology. 2018;73(3):454-463). Mast cells are multifunctional granulocytic immune cells derived from a common pluripotent myeloid progenitor, including eosinophils. Unlike other granulocytic cells, mast cell progenitors circulate in the bloodstream and migrate to all vascularized tissues where they differentiate and reside for long periods during homeostasis. Within the tissue, mast cells can be found at all layers from mucosa to submucosa, muscle, and serosa. They are also often found near blood vessels, nerves, or sites of environmental interaction. Mast cells are frequently categorized into connective tissue or mucosal type depending on their anatomic location. Mucosal mast cells are smaller and have lower histamine content and lifespan. Mast cells can also be classified by their preformed granule- associated protease content into two subsets: MCT, containing tryptase but little or no chymase, and MCTC, containing tryptase and chymase. MCT are predominant in the mucosa, whereas MCTC are more submucosal. In the esophagus, there is a unique mast cell characterized by high tryptaseand carboxypeptidase A3 (CP A3), but low chymase. In the mucosa, approximately 80% of the mast cells are MCT.

[0032] In embodiments, subjects with EoE have a peak pre-treatment mast cell count of 10 or more mast cells per HPF in at least one biopsy. In embodiments, subjects with EoE have a peak pre-treatment mast cell count of 15 or more mast cells per HPF in at least one biopsy. In embodiments, the mast cell count is measured in the distal portion of the esophagus, the proximal portion of the esophagus, or both. In embodiments, subjects with EoE have a peak pre-treatment mast cell count in the distal portion of the esophagus of 10 or more mast cells per HPF in at least one biopsy. In embodiments, subjects with EoE have a peak pre-treatment mast cell count in the distal portion of the esophagus of 15 or more mast cells per HPF in at least one biopsy. In embodiments, subjects with EoE have a peak pre-treatment mast cell count in the proximal portion of the esophagus of 10 or more mast cells per HPF in at least one biopsy. In embodiments, subjects with EoE have a peak pre-treatment mast cell count in the proximal portion of the esophagus of 15 or more mast cells per HPF in at least one biopsy.

[0033] In embodiments, the methods of the present disclosure lead to a reduction in mast cell count. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of no more than 10 mast cells per high power field (HPF) in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of no more than 6 mast cells per high power field (HPF) in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure involve measurement of the mast cell count in the distal portion of the esophagus, the proximal portion of the esophagus, or both. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the distal portion of the esophagus of no more than 6 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the distal portion of esophagus of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the proximal portion of the esophagus of no more than 6 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in theproximal portion of esophagus of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy.

[0034] In embodiments, the number of mast cells in a biopsy is counted less than about 7, less than about 14, or less than about 30 days prior to administration of a composition of the present disclosure (i.e., pre-treatment). In embodiments, the number of mast cells in a biopsy is counted after administration of a composition of the present disclosure for about 4 weeks, about 8 weeks, about 12 weeks, about 16 weeks, about 20 weeks, about 24 weeks, about 28 weeks, about 32 weeks, about 36 weeks, about 40 weeks, about 44 weeks, about 48 weeks, or about 52 weeks (i.e., post-treatment).

[0035] In embodiments, mast cell counts are obtained from multiple HPFs. In embodiments, multiple HPF s (e.g., 2, 3, 4, or 5 HPFs as described herein) can be obtained from a single biopsy, or in some cases from multiple biopsies. In embodiments, HPFs of the present disclosure may be obtained from 1, 2, 3, 4, or 5 samples (e.g., individual biopsies). By way of example, 5 HPFs may be from a total of 2 samples (e.g., 3 HPFs from one sample and 2 from the other, rather than requiring 5 HPFs from each of the two samples). In embodiments, multiple samples may be obtained from a single biopsy. For example, an esophageal biopsy may contain 4-6 samples representing different parts of the esophagus (e.g., 2 samples from the proximal esophagus, 2 samples from the middle esophagus, and 2 samples from the distal esophagus).

[0036] In embodiments, a numerical threshold value useful for diagnosing mast cell or eosinophilic esophagitis is a peak mast cell count of > 10 mast cells per HPF in at least one biopsy. In embodiments, a numerical threshold value useful for diagnosing mast cell or eosinophilic esophagitis is a peak mast cell count of > 15 mast cells per HPF in at least one biopsy. In embodiments, a numerical threshold value useful for determining mast cell remission is a peak mast cell count of < 6 mast cells per HPF in at least one biopsy. In embodiments, a numerical threshold value useful for determining mucosa normalization is a peak mast cell count of < 6 mast cells per HPF in at least one biopsy. In embodiments, a numerical threshold value useful for determining EoE clinical remission is a peak mast cell count of < 6 mast cells per HPF in at least one biopsy.

[0037] In embodiments, the number of mast cells in a sample is counted by hematoxylin and eosin (H&E) staining. In embodiments, the number of mast cells in a sample is counted by immunohistochemical (IHC) staining for a mast cell marker, including without limitation tryptase,chymase, CD117 (c-kit), or IgE receptor. In embodiments, mast cells are detected by metachromatic stain selected from Romanowsky combinations, toluidine blue, and Alcian blue.

[0038] In embodiments, mast cell burden can be assayed by measuring biomarkers in serum, blood, or urine. In embodiments, an individual that tests for abnormally high levels in one or more of these assays may be treated using the methods of the present disclosure. In embodiments, number and / or activity of mast cells in an individual are assayed by serum tryptase or beta tryptase. In embodiments, the number of mast cells in an individual is assayed by blood level(s) of tryptase, histamine, leukotriene e4, prostaglandin D2, and / or heparin. In embodiments, the number of mast cells in an individual is assayed by urine level(s) of N-methyl-histamine, prostaglandin F2 alpha, and / or prostaglandin D2. In embodiments, the biomarkers in serum, blood, or urine are measured described herein or well known to one of skill in the art (e.g., an ELISA or Western blot assay).

[0039] In embodiments, the methods of the present disclosure are utilized to inhibit or reduce mast cell activation (MCA). Mast cells can be activated rapidly and release preformed proteases and small molecules through a process called degranulation in addition to slower de novo secretion of cytokines and chemokines. The preformed molecules include the bioactive amine histamine, and proteases such as tryptase, carboxypeptidase A3 (CP A3), and cathepsin G. Mast cell activation (MCA) also leads to synthesis of de-novo mediators such as prostaglandins (e.g. Prostaglandin D2), leukotrienes (e.g. leukotriene C4), cytokines (IL-13, TGF0), and chemokines. As mast cells can release a large number of molecules following activation, they have been implicated in a number of diseases including EoE, inflammatory bowel disease, irritable bowel syndrome, and cancer.

[0040] In embodiments, mast cell activation is detected (e.g., activated mast cells are detected) by IHC staining for tryptase and quantifying mast cell degranulation. In embodiments, mast cell activation is detected (e.g., activated mast cells are detected) by staining for markers of mast cell activation (including without limitation CD63 and / or CD107a), e.g., by flow cytometry or IHC.

[0041] In embodiments, mast cell activity can be assayed by measuring biomarkers in serum, blood, or urine. In embodiments, activity of mast cells in an individual is assayed by blood level(s) of tryptase, histamine, leukotriene e4, prostaglandin D2, and / or heparin. In embodiments, activity of mast cells in an individual is assayed by urine level(s) of N-methyl-histamine, prostaglandin F2 alpha, and / or prostaglandin D2.

[0042] In embodiments, the methods of the present disclosure are utilized to reduce expression of one or more mast cell activation (MCA) transcriptional signatures. In embodiments, the MCA transcriptional signature is selected from tryptase (TPSAB1), carboxypeptidase A3 (CPA3), chymase (CMA1), suppression of tumorigenicity 2 (A72), Cathepsin G (CTSG), 5-lipoxygenase- activating protein (ALOX5AP), prostaglandin-endoperoxide synthase 2 (PTGS2), C-C motif ligand 2 (CCL2), vascular endothelial growth factor A (PEG FA), interleukin 5 (IL5), interleukin 13 (7 LI 3), interleukin 1 receptor-like 1 (IL1RL1), transforming growth factor beta (TGFfJ), Fc epsilon receptor 1A (FCER1A), aryl hydrocarbon receptor (A777?), cytokine receptor common subunit 0 (CSF2RB), membrane spanning 4-domains A2 (MS4A2), c-KIT (KIT), interleukin 9 receptor (IL9R).

[0043] In embodiments, the expression of one or more mast cell activation (MCA) transcriptional signatures in a sample is determined by RT-PCR or single-cell RNA sequencing.

[0044] In embodiments, the methods of the present disclosure are utilized to reduce transient mast cells, persistent mast cells and / or proliferative mast cells. In embodiments, mast cells (MCs) are classified into 4 subtypes: resident MCs, transient MCs, persistent MCs and proliferative MCs. In embodiments, In embodiments, resident MCs are present mainly in the esophageal lamina propria during homeostatic conditions. They are characterized as TPSABShlghAREGhlgh. In embodiments, subjects with inactive EoE (Peak eosinophil count < 15 eos / HPF) have a small number of persistent mast cells, which have a transcriptome that is more activated than resident mast cells. In embodiments, mast cells expand and infiltrate into the esophageal epithelium and proliferate locally in active EoE (Peak eosinophil count > 15 eos / HPF). They are characterized by the accumulation of KIT^^ILl RLI^FCERIA1transient and CA4 / 17hlghC7 Ghlghpersistent EoE- specific MCs populations, each of which are associated with the A7A767lllgl1proliferative cluster. In embodiments, proliferative MCs are characterized as MKI67h''^T()IGAh'^4TFAh'^XIAA(H()lh'~'n. In embodiments, the transient MCs is abolished in disease remission. In embodiments, both CSFlhlghresident and CAM7hlghCESGhlghpersistent MCs remain transcriptionally activated even in disease remission. In embodiments, MCs exhibit increased local proliferation in the esophagus associated with the increased proliferation of the transient and the persistent MC populations in EoE. In embodiments, transient, persistent and / or proliferative MC populations are diminished in disease remission.

[0045] In embodiments, the numbers of resident MCs, transient MCs, persistent MCs and proliferative MCs in a sample are counted by immunohistochemical (IHC) staining for a mast cell marker, including without limitation TPSABS, AREG, KIT, IL1RL, FCER1A, CMA1, CTSG, MKI67, TOP 2 A, PCNA, or KI AA0101.

[0046] In embodiments, the methods of the present disclosure are utilized to reduce mast cell degranulation. Mast cell degranulation liberates numerous vasoactive, proinflammatory and proteolytic substances such as histamine, chemokines, lipases, proteases, kinins, cytokines, arachidonic acid derivatives and nitric oxide. In embodiments, mast cell degranulation can be assayed, for example, by measuring histamine release with high-performance liquid chromatography (see, e.g., Taylor et al. 1995 Immunology 86(3): 427-433 and Kurosawa et al., 1998 Clin Exp Allergy 28(8): 1007-1012).

[0047] In embodiments, a reduced peak mast cell count correlates with a reduced peak eosinophil count. In embodiments, a reduced peak mast cell count correlates with mucosal normalization. In embodiments, a reduced peak mast cell count correlates with a positive clinical response to treatment. In embodiments, peak mast cell counts correlate with symptom scores in a subject with EoE. In embodiments, a reduced peak mast cell count correlates with an improved symptom score. In embodiments, reduced expression of mast cell-associated genes correlates with improved symptom scores. In embodiments, reduced expression of MCA transcriptional signatures correlates with improved symptom scores. In embodiments, diminished transient mast cells, persistent mast cells and proliferative mast cells correlate with improved symptom scores.Corticosteroids and additional therapeutic agents

[0048] In embodiments, any therapeutic agent, which can treat or ameliorate eosinophilic esophagitis, can be used in the methods described herein. In embodiments, any therapeutic agent, which can alter number, activity, and / or subtypes of mast cells, can be used in the methods described herein. Suitable therapeutic agents include those that reduce esophageal inflammation, reduce the number of esophageal eosinophils, or a combination thereof.

[0049] In embodiments, methods of the present disclosure involve the administration of one or more corticosteroids to a subject with eosinophilic esophagitis. Suitable corticosteroids include, but are not limited to hydrocortisone, prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, etc. or mineralocorticoid potencies (e.g., aldosterone), budesonide, fluticasone, flunisolide, ciclesonide, mometasone, beclomethasone, tixocortol andsalts, or esters and mixtures thereof. In embodiments, budesonide is administered to a subject in need. In embodiments, the therapeutic agent is fluticasone, or an ester thereof. In embodiments, the therapeutic agent is fluticasone propionate.

[0050] In embodiments, the methods of the disclosure involve administration of an oral dosage form of fluticasone propionate. Fluticasone propionate (FP) is a medium-potency synthetic corticosteroid having the chemical name S- (fluoromethyl)-6a,9-difluoro-l 10, 17-dihydroxy-16a- methyl-3-oxoandrosta-l, 4-diene-170- carbothioate, 17-propanoate. The molecular formula of fluticasone propionate is C25H31F3O5S. The chemical structure of fluticasone propionate is:

[0051] Fluticasone propionate (also referred to herein as “FP”) is a white to off-white powder. It is freely soluble in dimethyl sulfoxide and dimethylformamide, sparingly soluble in acetone, dichloromethane, ethyl acetate and chloroform, slightly soluble in methanol and 95% ethanol, and practically insoluble in water. FP decomposes without melting. The onset of decomposition occurs at about 225°C.

[0052] In embodiments, fluticasone propionate is formulated as an orally disintegrating (also referred to as orally dispersing or orodispersible) tablets with an excipient mixture consisting of crospovidone, mannitol colloidal silicon dioxide, silicified microcrystalline cellulose, sucralose, and sodium stearyl fumarate. In embodiments, the orally disintegrating table comprises about 1.5 or 3.0 mg of fluticasone propionate. In embodiments, the ODT is described in US 8,771,729 or US 10,471,071, each of which are herein incorporated by reference.

[0053] Fluticasone propionate is a medium-potency glucocorticoid with anti-inflammatory including anti-eosinophilic activity in vitro and in vivo. It has proven efficacy to treat conditions believed to have a similar pathophysiology as EoE, including asthma, allergic rhinitis, and atopic dermatitis, and has been marketed worldwide since the early 1990s in topical and inhalation products. Topical (delivered to the throat and swallowed) fluticasone propionate has demonstrated efficacy in resolving acute clinical and pathological features of EoE. In embodiments, anorodispersible (or orally disintegrating) tablet (ODT) form of fluticasone propionate is used for the treatment of EoE. In embodiments, ODTs are designed to release the drug in the oral cavity before swallowing without the ingestion of liquids. Thereby, the active substance is delivered directly to the site of action: the oesophagus.

[0054] In embodiments, one or more additional therapeutic agents may be co-administered with the corticosteroid. Such therapeutic agents include proton pump inhibitors (PPI), including, but not limited to, omeprazole, lansoprazole, dexlansoprazole, rabeprazole, pantoprazole, and esomeprazole.

[0055] In embodiments, the additional therapeutic agent comprises one or more immunosuppressant. Suitable immunosuppressants include, but are not limited to, cyclosporine, tacrolimus, prednisolone, hydrocortisone, sirolimus, everolimus, azathioprine, mycophenolic acid, methotrexate, basiliximab, daclizumab, rituximab, mepolizumab (anti-IL-5), reslizumab (anti-IL- 5), QAX576 (anti-IL-13), omalizumab (anti-immunoglobulin-E), infliximab (anti-TNF-a), antithymocyte globulin, and anti-lymphocyte globulin.

[0056] In embodiments, the pharmaceutical compositions disclosed herein are co-administered with one or more antibodies. Suitable anti-bodies include, include IL-4, IL-5, and IL- 13 antibodies. Non-limiting examples include basiliximab, daclizumab, rituximab, mepolizumab (anti-IL-5), reslizumab (anti-IL-5), QAX576 (anti-IL-13), and omalizumab (anti-immunoglobulin-E).

[0057] In embodiments, the one or more therapeutic agents may be “co-administered”, i.e., administered together in a coordinated fashion to a subject, either as separate pharmaceutical compositions or admixed in a single pharmaceutical composition. By “co-administered”, the one or more therapeutic agents may also be administered simultaneously with the present pharmaceutical compositions, or be administered separately, including at different times and with different frequencies. The one or more therapeutic agents may be administered by any known route, such as orally, intravenously, intramuscularly, nasally, subcutaneously, and the like; and the therapeutic agent may also be administered by any conventional route.

[0058] In embodiments, the therapeutic agents in the above paragraphs can be combined. When two or more medicines are used in combination, dosage of each medicine is commonly identical to the dosage of the medicine when used independently. If a medicine interferes with metabolism of other medicines, the dosage of each medicine is properly adjusted. Each medicine may be administered simultaneously or separately in an appropriate time interval.

[0059] In embodiments, the therapeutic agent for use in the present methods can be formulated into any appropriate dosage form, such as oral orally, parenterally, by inhalation spray, or topically, in formulations containing pharmaceutically acceptable carriers, adjuvants and vehicles. The term parenteral as used here includes subcutaneous, intravenous, intramuscular, and intraarterial injections with a variety of infusion techniques.

[0060] In embodiments, the pharmaceutical compositions used in (or for use in) the methods described herein can be any dosage form which can topically administer a corticosteroid to the esophagus. Non-limiting examples of suitable dosage forms include liquid compositions (e.g., solutions, suspensions, and slurries), gels, and solid compositions which form a liquid or gel after oral administration. For example, orally disintegrating compositions (e.g., ODT, effervescent, film, lyophilize matrix, or wafer), lozenges, and lollipops can from a solution, suspension, or gel comprising the therapeutic agent in the oral cavity of the patient, and after the solution or suspension is swallowed, the corticosteroid dissolved or suspended therein contacts the esophagus as the liquid traverses the esophageal tract. In a preferred embodiment, the pharmaceutical composition is in the form of an ODT.

[0061] Wafers can include dried or lyophilized compositions such as orally disintegrating or dissolving dosage forms prepared using Zydis® lyophilization technology (e.g., as described in U.S. Pat. No. 6,316,027), containing a corticosteroid as the active pharmaceutical ingredient. Film dosage forms can include edible films such as those described in U.S. Pat. No. 6,596,298 or U.S. Pat. No. 6,740,332, containing a corticosteroid as the active pharmaceutical ingredient. In embodiments, the solid composition comprises a lyophilized matrix, wherein the lyophilized matrix comprises a corticosteroid, the carrier and excipient. Suitable excipients include, but are not limited to, mannitol, xylitol, sorbitol, maltol, maltitol, lactose, sucrose, maltose, and combinations thereof.

[0062] Effervescent tablets and effervescent orally dispersing tablets can include those disclosed in U.S. Pat. No. 9,867,780 and U.S. Pat. No. 8,580,300. Such formulations contain weak acids or salts of weak acids, such as tartaric acid, acetic acid, lactic acid, or citric acid, or pharmaceutically acceptable salts thereof, such as magnesium, calcium, or sodium salts. These formulations may also include pharmaceutically acceptable excipients that release CO2 upon contact with water (e.g., saliva), such as carbonic acid, and salts of carbonates and bicarbonates, such as sodium andpotassium salts. In embodiments, such effervescent tablets are formulated to dissolve in a solution prior to oral administration. Such formulations may further comprise polyvinylpyrrolidone.Dosins

[0063] In embodiments, the methods of the disclosure involve administration of a therapeutically effective dose of fluticasone propionate. In embodiments, the therapeutically effective dose is from about 0.5 mg to about 5 mg of fluticasone propionate. In embodiments, fluticasone propionate is administered in a dose of about 0.5 mg, about 0.6 mg, about 0.7 mg, about 0.8 mg, about 0.9 mg, about 1.0 mg, about 1.1 mg, about 1.2 mg, about 1.3 mg, about 1.4 mg, about 1.5 mg, about 1.6 mg, about 1.7 mg, about 1.8 mg, about 1.9 mg, about 2.0 mg, about 2.1 mg, about 2.2 mg, about2.3 mg, about 2.4 mg, about 2.5 mg, about 2.6 mg, about 2.7 mg, about 2.8 mg, about 2.9 mg, about 3.0 mg, about 3.1 mg, about 3.2 mg, about 3.3 mg, about 3.4 mg, about 3.5 mg, about 3.6 mg, about 3.7 mg, about 3.8 mg, about 3.9 mg, about 4.0 mg, about 4.1 mg, about 4.2 mg, about4.3 mg, about 4.4 mg, about 4.5 mg, about 4.6 mg, about 4.7 mg, about 4.8 mg, about 4.9 mg, or about 5.0 mg. In embodiments, 1.5 mg of fluticasone propionate or an equipotent dose of a corticosteroid is administered. In embodiments, 3.0 mg of fluticasone propionate or an equipotent dose of a corticosteroid is administered.

[0064] While the compositions and methods described herein use or refer to a dose of fluticasone propionate, the disclosure envisions using other corticosteroids and obtaining substantially similar efficacy, improvements in symptoms scores, and reduction in candidiasis. The disclose envisions that such corticosteroid are used in an equipotent to fluticasone propionate to achieve the efficacy and symptom scores described herein. In embodiments, the corticosteroid has an equipotent dose to 1.5 mg or 3.0 mg of fluticasone propionate. A person of skill in the art could determine the equipotent dose based on the corticosteroid’s relative glucocorticoid receptor binding affinity or the relative potency of the corticosteroid’s anti-inflammatory activity. In embodiments, the equipotent dose is calculated based on the relative glucocorticoid activity corticosteroid’s relative glucocorticoid receptor binding affinity. The glucocorticoid receptor binding affinity gives a measure of the dose necessary to occupy 50 % of the glucocorticoid receptors. TABLE 1 gives the relative glucocorticoid receptor binding affinities for a number of corticosteroids. In embodiments, pharmacokinetic / pharmacodynamic modelling is utilized to estimate the equipotent dose of corticosteroid. The following article which describes methods of calculating equipotent doses isincorporated by reference in its entirety herein: Daley- Yates, Br J Clin Pharmacol. 2015 Sep; 80(3): 372-380.

[0065] In embodiments, the methods of the disclosure provide administration of a corticosteroid in an amount ranging from about 1 mg to about 5 mg, including 1 mg, 1.5 mg, 2 mg, 2.5 mg, 3, mg, 3.5 mg 4, mg, 4.5 mg, and 5 mg. In embodiments, the equipotent dose of a corticosteroid is from 0.05 mg to 20 mg. In embodiments, the equipotent dose of a corticosteroid ranged from about 0.05 mg to about 20 mg, e.g., about 0.05 mg, or about 0.1 mg, or about 0.15 mg, or about 0.2 mg, or about 0.25 mg, or about 0.30 mg, or about 0.35 mg, or about 0.40 mg, or about 0.45 mg, or about 0.50 mg, or about 0.55 mg, or about 0.60 mg, or about 0.65 mg, or about 0.70 mg, or about 0.75 mg, or about 0.80 mg, or about 0.85 mg, or about 0.9 mg, or about 0.95 mg, or about 1.0 mg, or about 1.5 mg, or about 2.0 mg, or about 2.5 mg, or about 3.0 mg, or about 3.5 mg, or about 4.0 mg, or about 4.5 mg, or about 5.0 mg, or about 5.5 mg, or about 6.0 mg, or about 6.5 mg, or about 7.0 mg, or about 7.5 mg, or about 8.0 mg, or about 8.5 mg, or about 9.0 mg, or about 9.5 mg, or about 10.0 mg, or about 10.5 mg, or about 11.0 mg, or about 11.5 mg, or about 12.0 mg, or about 12.5 mg, or about 13.0 mg, or about 13.5 mg, or about 14.0 mg, or about 14.5 mg, or about 15.0 mg, or about 15.5 mg, or about 16.0 mg, or about 16.5 mg, or about 17.0 mg, or about 17.5 mg, or about 18.0 mg, or about 19.0 mg, or about 19.5 mg, or about 20.0 mg, including all ranges between these values. Non-limiting examples of corticosteroids include hydrocortisone, prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, etc. or mineralocorticoid potencies (e.g., aldosterone), budesonide, fluticasone, flunisolide, ciclesonide, mometasone, beclomethasone, tixocortol and salts, or esters and mixtures thereof.

[0066] In embodiments, the methods of the disclosure involve administration of a total daily dose. As defined herein, the “total daily dose” is the total amount of fluticasone propionate or an equipotent dose of a corticosteroid administered in one day. As discussed herein, once-daily administration of a corticosteroids, according to the methods disclosed herein, improves a subject’s symptom scores (as described herein) while also reducing the subject’s risk of candidiasis. The total daily dose for once-daily administration may be the same or different as the total daily dose for the twice-daily administration. In embodiments, the total daily dose for twice daily administration is the same as the total daily dose of once daily administration. For example, the total daily dose for once-daily and twice-daily administration may be 1.5 mg or 3.0 mg fluticasone propionate. In embodiments, the total daily dose for twice daily administration is more than the total daily dose for the once daily administration. For example, a subject may be administered 1.5 mg fluticasone propionate once-daily, and the subject’s symptoms scores and risk of candidiasis may be compared to a subj ect that receives a total daily dose of 3.0 mg, 4.5 mg, or 6 mg fluticasone propionate, twice-daily. As another example, the subject may be administered 3 mg of a corticosteroid once-daily, and the subject’s symptoms scores and risk of candidiasis may be compared to a subject that receives a total daily dose of 4.5 mg or 6 mg fluticasone propionate, twice-daily.Dosins Regimens

[0067] In embodiments, the methods of the present disclosure offer dosing regimens. In embodiments, according to the methods of the disclosure, fluticasone propionate is administered once daily. In embodiments, according to the methods of the present disclosure, fluticasone propionate is administered once a day at bedtime or night time (HS). As defined herein, bedtime is the time at which a subject desires to go to sleep. In embodiments, fluticasone propionate is administered within 30 minutes, or 1 hour, or 1.5 hours, or 2 hours, or 2.5 hours, or 3.0 hours of a subject’s bedtime. In embodiments, fluticasone propionate is administered within 30 minutes of a subject’s bedtime. In embodiments, fluticasone propionate is administered while the subject is lying down or immediately prior to the subject lying down. As used herein, “immediately prior to the subject lying down” means within 30 minutes of the subject lying down, e.g., within 25, 20, 15, 10 or 5 minutes of the subject lying down. In embodiments, fluticasone propionate is administered once daily at about 6 p.m., about 6:30 p.m., about 7:00 p.m., about 7:30 p.m., about 8:00 p.m., about 8:30 p.m., about 9:00 p.m., about 9:30 p.m., about 10:00 p.m., about 10:30 p.m.,about 11:00 p.m., or about 12:00 a.m. In embodiments, fluticasone propionate is administered to a subject on an empty stomach (e.g. at least two hours after eating or at least one hour before eating; or at least 30 minutes before or after eating).

[0068] In embodiments, the methods of the disclosure involve administration of an equipotent dose of corticosteroid. In embodiments, according to the methods of the disclosure, the equipotent dose of corticosteroid is administered once daily. In embodiments, according to the methods of the present disclosure, the equipotent dose of corticosteroid is administered once a day at bedtime or night time (HS). In embodiments, the equipotent dose of corticosteroid is administered within 30 minutes, or 1 hour, or 1.5 hours, or 2 hours, or 2.5 hours, or 3.0 hours of a subject’s bedtime. In embodiments, the equipotent dose of corticosteroid is administered while the subject is lying down or immediately prior to the subject lying down. In embodiments, the equipotent dose of a corticosteroid is administered once daily at about 6 p.m., about 6:30 p.m., about 7:00 p.m., about 7:30 p.m., about 8:00 p.m., about 8:30 p.m., about 9:00 p.m., about 9:30 p.m., about 10:00 p.m., about 10:30 p.m., about 11:00 p.m., or about 12:00 a.m. In embodiments, the equipotent dose of a corticosteroid is administered to a subject on an empty stomach (e.g. at least two hours after eating or at least one hour before eating; or at least 30 minutes before or after eating).

[0069] In embodiments, fluticasone propionate or an equipotent dose of a corticosteroid are administered for a defined length of time. In embodiments, the methods of the disclosure provide administration of fluticasone propionate or the corticosteroid is administered for about 12 weeks to at least one year. In embodiments, the length of time is at least 12 weeks, or at least 13 weeks, or at least 14 weeks, or at least 15 weeks, or at least 16 weeks, or at least 17 weeks, or at least 18 weeks, or at least 19 weeks, or at least 20 weeks, or at least 21 weeks, or at least 22 weeks, or at least 23 weeks, or at least 24 weeks, or at least 25 weeks, or at least 26 weeks, or at least 27 weeks, or at least 28 weeks, or at least 29 weeks, or at least 30 weeks, or at least 31 weeks, or at least 32 weeks, or at least 33 weeks, or at least 34 weeks, or at least 35 weeks, or at least 36 weeks, or at least 37 weeks, or at least 38 weeks, or at least 39 weeks, or at least 40 weeks, or at least 41 weeks, or at least 42 weeks, or at least 43 weeks, or at least 44 weeks, or at least 45 weeks, or at least 46 weeks, or at least 47 weeks, or at least 48 weeks, or at least 49 weeks, or at least 50 weeks, or at least 51 weeks, or at least 52 weeks, or more (e.g., 1 year, 1.5 years, 2, years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, and so on).

[0070] In embodiments, the treatment of EoE with a corticosteroid is stopped for a defined length of time to allow the subject to recover from treatment. In embodiments, the length of time is at least 1 week, or at least 2 weeks, or at least 3 weeks, or at least 4 weeks, or at least 5 weeks, or at least 6 weeks, or at least 7 weeks, or at least 8 weeks, or at least 9 weeks, or at least 10 weeks, or at least 11 weeks, or at least 12 weeks, or at least 13 weeks, or at least 14 weeks, or at least 15 weeks, or at least 16 weeks, or at least 17 weeks, or at least 18 weeks, or at least 19 weeks, or at least 20 weeks, or at least 21 weeks, or at least 22 weeks, or at least 23 weeks, or at least 24 weeks, or at least 25 weeks, or at least 26 weeks, or at least 27 weeks, or at least 28 weeks, or at least 29 weeks, or at least 30 weeks, or at least 31 weeks, or at least 32 weeks, or at least 33 weeks, or at least 34 weeks, or at least 35 weeks, or at least 36 weeks, or at least 37 weeks, or at least 38 weeks, or at least 39 weeks, or at least 40 weeks, or at least 41 weeks, or at least 42 weeks, or at least 43 weeks, or at least 44 weeks, or at least 45 weeks, or at least 46 weeks, or at least 47 weeks, or at least 48 weeks, or at least 49 weeks, or at least 50 weeks, or at least 51 weeks, or at least 52 weeks, or more.

[0071] In embodiments, treatment is stopped for a defined length of time and then restarted. In embodiments, treatment is restarted after 1 week, or at least 2 weeks, or at least 3 weeks, or at least 4 weeks, or at least 5 weeks, or at least 6 weeks, or at least 7 weeks, or at least 8 weeks, or at least 9 weeks, or at least 10 weeks, or at least 11 weeks, or at least 12 weeks, or at least 13 weeks, or at least 14 weeks, or at least 15 weeks, or at least 16 weeks, or at least 17 weeks, or at least 18 weeks, or at least 19 weeks, or at least 20 weeks, or at least 21 weeks, or at least 22 weeks, or at least 23 weeks, or at least 24 weeks, or at least 25 weeks, or at least 26 weeks, or at least 27 weeks, or at least 28 weeks, or at least 29 weeks, or at least 30 weeks, or at least 31 weeks, or at least 32 weeks, or at least 33 weeks, or at least 34 weeks, or at least 35 weeks, or at least 36 weeks, or at least 37 weeks, or at least 38 weeks, or at least 39 weeks, or at least 40 weeks, or at least 41 weeks, or at least 42 weeks, or at least 43 weeks, or at least 44 weeks, or at least 45 weeks, or at least 46 weeks, or at least 47 weeks, or at least 48 weeks, or at least 49 weeks, or at least 50 weeks, or at least 51 weeks, or at least 52 weeks, or more. Temporarily stopping the corticosteroid is a known as a drug “holiday”, and, In embodiments, it may help to reduce cortisol suppression and other side effects associated with long-term corticosteroid use.Outcomes

[0072] In embodiments, administration of fluticasone propionate or an equipotent dose of a corticosteroid once daily results in an improvement in one or more outcomes when compared to baseline. Non-limiting examples of patient outcomes include: a reduced peak mast cell count; reduced mast cell activation; a reduced transient mast cell count; a reduced persistent mast cell count; a reduced proliferative mast cell count; mucosal healing or normalization; a reduced risk or incidence of candidiasis; at least one symptom score measured using a patient reported outcome symptom evaluation (PROSE) instrument after an each episode of dysphagia (see e.g., WO 2019 / 165138) or the 24-hour diary (see e.g., US Publication No. 2016 / 0078186); the EoE Endoscopic Reference (EREF) score; the EoE Activity Index (EEsAI) avoidance, modification, and slow swallowing (AMS) score; the global EoE score; the eosinophilic esophagitis quality of life questionnaire; the patient global impression of severity (PGIS); and the patient global impression of change (PGIC).

[0073] A patient’s risk of candidiasis is determined from the incidence rate in the clinical trial population. The incidence rate of candidiasis is the number of subjects that reported a candidiasis infection divided by the total number of subjects treated with the corticosteroid during treatment.

[0074] In embodiments, baselines are measured 1 day, or 2 days, or 3 days, or 4 days, or 5 days, 6 days, or 1 week, or 2 week, or 3 week, or 4 week, or 5 weeks, or 6 weeks prior to initiation of treatment according to the methods of the disclosure.

[0075] In embodiments, outcomes are measured 1 week, or 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks, or 6 weeks, or 7 weeks, or 8 weeks, or 9 weeks, or 10 weeks, or 11 weeks, or 12 weeks, or13 weeks, or 14 weeks, or 5 weeks, or 1 5 weeks, or 17weeks, or 11 weeks, or 19 weeks, or 20 weeks, or 21 weeks, or 22 weeks, or 23 weeks, or 24 weeks, or 25 weeks, or 26 weeks, or 27 weeks, or 28 weeks, or 29 weeks, or 30 weeks, or 31 weeks, or 32 weeks, or 33 weeks, or 34 weeks, or 35 weeks, or 36 weeks, or 37 weeks, or 38 weeks, or 39 weeks, or 40 weeks, or 41 weeks, or 42 weeks, or 43 weeks, or 44 weeks, or 45 weeks, or 46 weeks, or 47 weeks, or 48 weeks, or 49 weeks, or 50 weeks, or 51 weeks, or 52 weeks, or 53 weeks, or 54 weeks, or 55 weeks, or 56 weeks, or 57 weeks, or 58 weeks, or 59 weeks, or 60 weeks, or 61 weeks, or 62 weeks, or 63 weeks, or 64 weeks, or 65 weeks, or 66 weeks, or 67 weeks, or 68 weeks, or 69 weeks, or 70 weeks, or 71 weeks, or 72 weeks, or 73 weeks, or 74 weeks, or 75 weeks, or 76 weeks, or 77 weeks, or 78 weeks, or 79 weeks, or 80 weeks, or 81 weeks, or 82 weeks, or 83weeks, or 84 weeks, or 85 weeks, or 86 weeks, or 87 weeks, or 88 weeks, or 89 weeks, or 90 weeks, or 91 weeks, or 92 weeks, or 93 weeks, or 94 weeks, or 95 weeks, or 96 weeks, or 97 weeks, or 98 weeks, or 99 weeks, or 100 weeks, or 101 weeks, or 102 weeks, or 103 weeks, or 104 weeks, or more weeks after initiation of treatment according to the methods of the disclosure. In embodiments, the methods of the disclosure result in an improvement in outcomes at after initiation of treatment according to the methods of the disclosure at 1 week, or 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks, or 6 weeks, or 7 weeks, or 8 weeks, or 9 weeks, or 10 weeks, or 11 weeks, or 12 weeks, or 13 weeks, or 14 weeks, or 15 weeks, or 16 weeks, or 17 weeks, or 18 weeks, or 19 weeks, or 20 weeks, or 21 weeks, or 22 weeks, or 23 weeks, or 24 weeks, or 25 weeks, or 26 weeks, or 27 weeks, or 28 weeks, or 29 weeks, or 30 weeks, or 31 weeks, or 32 weeks, or 33 weeks, or 34 weeks, or 35 weeks, or 36 weeks, or 37 weeks, or 38 weeks, or 39 weeks, or 40 weeks, or 41 weeks, or 42 weeks, or 43 weeks, or 44 weeks, or 45 weeks, or 46 weeks, or 47 weeks, or 48 weeks, or 49 weeks, or 50 weeks, or 51 weeks, or 52 weeks, or 53 weeks, or 54 weeks, or 55 weeks, or 56 weeks, or 57 weeks, or 58 weeks, or 59 weeks, or 60 weeks, or 61 weeks, or 62 weeks, or 63 weeks, or 64 weeks, or 65 weeks, or 66 weeks, or 67 weeks, or 68 weeks, or 69 weeks, or 70 weeks, or 71 weeks, or 72 weeks, or 73 weeks, or 74 weeks, or 75 weeks, or 76 weeks, or 77 weeks, or 78 weeks, or 79 weeks, or 80 weeks, or 81 weeks, or 82 weeks, or 83 weeks, or 84 weeks, or 85 weeks, or 86 weeks, or 87 weeks, or 88 weeks, or 89 weeks, or 90 weeks, or 91 weeks, or 92 weeks, or 93 weeks, or 94 weeks, or 95 weeks, or 96 weeks, or 97 weeks, or 98 weeks, or 99 weeks, or 100 weeks, or 101 weeks, or 102 weeks, or 103 weeks, or 104 weeks, or more weeks. In embodiments, the methods of the disclosure result in an improvement in any of the outcomes described herein for at least 52 weeks.

[0076] In embodiments, the risk of candidiasis and an improvement in at least one of the outcomes are measured at week 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and / or 12.

[0077] In embodiments, the risk of candidiasis and an improvement in at least one of the outcomes again at week 24 and / or week 52 (or any week therebetween).

[0078] In embodiments, the methods of the disclosure lead to a reduction in peak mast cell count compared to the subject’s baseline mast cell levels. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of no more than 10 mast cells per HPF, or 9 mast cells per HPF, or 8 mast cells per HPF, or 7 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of nomore than 6 mast cells per high power field (HPF) in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a reduction in the peak post-treatment mast cell count per HPF by at least about 10%, at least about15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about95%, or at least about 98% compared to the subject’s baseline mast cell counts. In embodiments, the methods of the disclosure involve measurement of the mast cell count in the distal portion of the esophagus, the proximal portion of the esophagus, or both. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the distal portion of esophagus of no more than 10 mast cells per HPF, or 9 mast cells per HPF, or 8 mast cells per HPF, or 7 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the distal portion of the esophagus of no more than 6 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak posttreatment mast cell count in the distal portion of esophagus of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the proximal portion of esophagus of no more than 10 mast cells per HPF, or 9 mast cells per HPF, or 8 mast cells per HPF, or 7 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the proximal portion of the esophagus of no more than 6 mast cells per HPF in at least one biopsy. In embodiments, the methods of the disclosure lead to a peak post-treatment mast cell count in the proximal portion of esophagus of no more than 5 mast cells per HPF, or 4 mast cells per HPF, or 3 mast cells per HPF, or 2 mast cells per HPF, or 1 mast cells per HPF in at least one biopsy. In embodiments, the reduction in the mast cell count correlates with the reduction in the eosinophil count in at least one biopsy of the esophagus. In embodiments, there is an agreement between the peak mast cell count of no more than 6 mast cells per HPF and the peak eosinophil count of no more than 6 eosinophils per HPF, wherein the agreement is at least about 80%, about 85%, about 90%, or about 95%. In embodiments, the agreement is at least about 85%. the reduction in the mastcell count correlates with mucosal healing in at least one biopsy of the esophagus. In embodiments, there is an agreement between the peak mast cell count of no more than 6 mast cells per HPF and mucosal normalization, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%. In embodiments, the agreement is at least about 70%. In embodiments, the reduction in the mast cell count correlates with an improved symptom score of EoE. In embodiments, there is an agreement between the peak mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus and an improved symptom score, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%. In embodiments, the correlation or agreement described herein are measured using a statistical method that is well known to one of skill in the art (e.g., scatter plot, Cohen’s kappa, Fleiss’s kappa, Weighted Kappa, Intra-class coefficient, Bland-Altman plots).

[0079] In embodiments, the methods of the present disclosure lead to a reduction in mast cell activation (MCA) compared to the subject’s baseline mast cell activation levels. In embodiments, the methods of the disclosure lead to a reduction in MCA by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline. In embodiments, the methods of the disclosure lead to a reduction in the expression and / or release of products of MCA and / or degranulation by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 98% relative to baseline. In embodiments, the methods of the disclosure lead to a reduction in the expression of one or more MCA transcriptional signatures selected from tryptase (TPSAB1), carboxypeptidase A3 (CPA3), chymase (CMA1), suppression of tumorigenicity 2 (ST2), Cathepsin G (CTSG), 5-lipoxygenase-activating protein (ALOX5AP), prostaglandin-endoperoxide synthase 2 (PTGS2), C-C motif ligand 2 (CCL2), vascular endothelial growth factor A (VEGFA), interleukin 5 (IL5), interleukin 13 (7 LI 3), interleukin 1 receptor-like 1 (IL1RL1), transforming growth factor beta (TGF ), Fc epsilon receptor 1A (FCER1A), aryl hydrocarbon receptor (A HR), cytokine receptor common subunit 0 (CSF2RB), membrane spanning 4-domains A2 (MS4A2), c-KIT (KIT), interleukin 9 receptor(IL9R by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline.

[0080] In embodiments, the methods of the present disclosure lead to a reduction of tryptase, histamine, leukotriene e4, prostaglandin F2 alpha, prostaglandin D2, and / or heparin in serum, blood, or urine by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline.

[0081] In embodiments, the methods of the present disclosure lead to a reduction in cell count of transient MCs, persistent MCs and / or proliferative MCs compared to the subject’s baseline mast cell levels. In embodiments, the methods of the present disclosure lead to a reduction in KIT^^ILIRLI^FCERIA^0^ transient mast cell counts by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 98% relative to baseline. In embodiments, the methods of the present disclosure lead to a reduction in CA 47hlghCT Ghlghpersistent mast cell counts by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline. In embodiments, the methods of the present disclosure lead to a reduction m MKI67h'°hT()I>2Ah'°hI’(’NAh'°hKIAA()l()lh'°hproliferative mast cell counts by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline.

[0082] In embodiments, the methods of the present disclosure lead to a reduction in mast cell degranulation compared to the subject’s baseline mast cell degranulation levels. In embodiments, the methods of the present disclosure lead to a reduction in mast cell degranulation by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at leastabout 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline. In embodiments, the methods of the present disclosure lead to a reduction in histamine release by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline.

[0083] In embodiment, the methods of the present disclosure lead to mucosal normalization compared to the subject’s baseline mucosal inflammation levels. In embodiment, the methods of the present disclosure lead to absence of one or more features selected from eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis.

[0084] In embodiments, the methods of the disclosure lead to a reduction in a subject’s risk of candidiasis, a potentially adverse effect of oral steroid usage. In embodiments, the methods of the disclosure provide an improvement in oral candidiasis, esophageal candidiasis, and / or oropharyngeal candidiasis. Oral, oropharyngeal, and oesophageal candidiasis infections are known side effects of swallowed corticosteroids, such as budesonide and fluticasone propionate, used for the treatment of EoE. Oral candidiasis is one of the most common fungal infections affecting the fungal mucosa. Oral candidiasis is described by Agrawal et al. in the following citation Agrawal, A., Singh, A., Verma, R., & Murari, A. (2014). Oral candidiasis: An overview. Journal of Oral and Maxillofacial Pathology, 18( ), 81. doi: 10.4103 / 0973-029x.141325; this reference is incorporated herein in its entirety. Oral candidiasis is caused by Candida albicans, Candida glabrata, Candida guillermondii, Candida krusei, Candida guillermondii, Candida krusei, Candida parapsilosis, Candida pseudotropicalis, Candida stellatoidea, and Candida tropicalis. Candida can also infect the esophagus. Esophageal candidiasis is most commonly caused by Candida albicans. Esophageal candidiasis is detailed by Nishimura et al. in the following citation Nishimura, S., Nagata, N., Shimbo, T., Asayama, N., Akiyama, J., Ohmagari, N., Uemura, N. (2013). Factors Associated with Esophageal Candidiasis and Its Endoscopic Severity in the Era of Antiretroviral Therapy. PLoS ONE, 5(3). doi:10.1371 / journal.pone.0058217 this reference is incorporated herein in its entirety. Without being bound by theory, it is postulated that subjects who receive steroids experience candidiasis by possibly suppressing local cellular immunity andphagocytosis. The methods described herein reduce immune suppression. In embodiments, according to the methods of the disclosure, a subject’s risk of oral candidiasis is less than about 10 % (e.g., about 10%, about 9%, about 8%, about 7%, about 6%, about 5%, about 4%, about 3%, about 2%, about 1% or less).

[0085] Candidiasis is diagnosed according to methods known to persons skilled in the art. In embodiments, oral specimens are grown on agar. Briefly, specimens are collected under aseptic conditions from active lesions. Specimens are kept moist and stored in a refrigerator at 4 °C. Smears are taken from the infected oral mucosa, rhagades, and fitting side of denture preferably with wooden spatulas. Smears were fixed immediately in ether / alcohol 1 : 1 or with spray fix. Dry preparations may be examined by Gram stain method and periodic acid Schiff (PAS) method. Swabs are seeded on various agar substrates to grow the yeast species. Pagano-Levin agar or Liftman’s substrate are useful supplements, because they enable distinction of yeasts on the basis of difference in colony color.

[0086] In embodiments, an imprint culture technique is utilized for quantitative assessment of yeast growth in different areas of the oral mucosa. Sterile, square plastic foam pads are dipped in peptone water and placed on the restricted area under study for 30-60 seconds and placed thereafter directly on Pagano-Levin or Sabouraud’s agar. Subsequently, candidal density at each site is determined by a Gallenkamp colony counter and expressed as colony forming units per mm2(CFU mm'2). This technique is useful for localizing the site of infection.

[0087] In embodiments, impression culture technique is used to estimate the number of colony forming units of yeast. Maxillary and mandibular alginate impressions are taken and cast in 6 % fortified agar, incorporated into Sabouraud’s dextrose broth, and grown for 48-72 hours at 37 °C, and the CFUs of yeast are estimated.

[0088] In embodiments, the number of Candida in a subject’s saliva is estimated by counting the resultant growth on Sabouraud’s agar using either the spiral plating or Miles and Misra surface viable counting technique. Subjects who display clinical signs of oral candidiasis usually have more than 400 CFU / mL.

[0089] In embodiments, commercial identification kits are utilized to identify candidiasis, including the Microstix-candida system, the O Yeast-I dent system, and the Ricult-N dip slide technique.

[0090] In embodiments, fungi in biopsy specimens are identified histologically. Hematoxylin and eosin poorly stain Candida species. The specific fungal stains such as PAS stain, Grocott-Gomori’s metheneamine silver (GMS) and Gridley stains are widely used for demonstrating fungi in the tissues, which are colored intensely with these stains.

[0091] In embodiments, physiological tests are used for definitive identification of Candida species. These tests involve the ability of the Candida species to assimilate and ferment individual carbon and nitrogen sources (see TABLE 2 and TABLE 3).

[0092] In embodiments, serological tests are utilized to detect invasive candidiasis including the detection of antibodies, immunodiffusion, slide agglutination, phytohemagglutination, coelectosynersis, immunoprecipitation, A and B immunofluorescence, nonspecific Candida antigens, latex agglutination, immunoblotting, 0-(l,3)-D-glucan, cell wall mannoprotein, cell wall components, and Candida enolase antigen testing.

[0093] In embodiments, an upper endoscopy is necessary for diagnosis, particularly if the candidiasis is an esophageal candidiasis. White-yellow plaques can be seen on upper endoscopy. Plaques and exudates are adherent to the mucosa and do not wash off with water irrigation. There may also be mucosal breaks or ulcerations. Hematoxylin and eosin stain of biopsies or brushing of esophageal candidiasis show pseudohyphae which is diagnostic for esophageal candidiasis. Pathology may demonstrate acute inflammation and / or intraepithelial lymphocytosis.

[0094] In embodiments, subjects treated according to the methods of the disclosure exhibit a risk of candidiasis of less than about 10 %. In embodiments, subjects treated according to the methods of the disclosure exhibit a risk of candidiasis of less than about 9 %, or less than about 8 %, or less than about 7 %, or less than about 6 %, or less than about 5 %, or less than about 4 %, or less than about 3 %, or less than about 2 % , or less than about 1 %. In embodiments, the methods of the present disclosure lead to a reduced incidence of candidiasis. In embodiments, incidences of candidiasis are reduced by about 1 %, about 5 %, about 10 %, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100%, inclusive of all values and ranges therein, compared to an otherwise identical subject that is treated with the corticosteroid twice daily.

[0095] In embodiments, according to the methods of the disclosure, a subject’s risk of oral candidiasis is less than about 4 %, less than about 3 %, less than about 2 %, or less than about 1 %. In embodiments, according to the methods of the disclosure, a subject’s risk of oral candidiasis is about 4.8 %. In embodiments, instances of oral candidiasis are reduced by about 1 %, about 5 %, about 10 %, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100%, inclusive of all values and ranges therein, compared to an otherwise identical subject that is treated with the corticosteroid twice daily.

[0096] In embodiments, according to the methods of the disclosure, a subject’s risk of esophageal candidiasis is less than about 10 %. In embodiments, according to the methods of the disclosure, a subject’s risk of esophageal candidiasis is less than about 10 %, or 9 %, or 8 %, or 7 %, or 6 %, or 5 %, or 4 %, or 3 %, or 2 %, or 1 %. In embodiments, instances of esophageal candidiasis are reduced by about 1 %, about 5 %, about 10 %, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 100%, inclusive of all values and ranges therein, compared to an otherwise identical subject that is treated with the corticosteroid twice daily.

[0097] In embodiments, the methods of the present disclosure cause subjects to show an improvement in at least one symptom score measured using a patient reported outcome evaluation (PROSE) instrument after an episode of dysphagia. The PROSE instrument computes several items, including the number of real-time episode entry (RTE) dysphagia episodes, the number of end of day recorded dysphagia episodes, the total number of dysphagia episodes, the proportion of RTE dysphagia episodes, the total duration of dysphagia, the total imputed duration of dysphagia, the number of dysphagia free days, the worst difficulty recorded in an RT episode, the worst pain recorded in an RT episode, the worst discomfort recorded in an RT episode, the worst composite symptom summary score, the worst difficulty recorded in an EOD episode, the worst pain recorded in an EOD episode, the worst discomfort recorded in an EOD episode, the worst composite symptom summary score, maximum reported difficulty response, maximum reported pain response, maximum reported discomfort response, and the worst composite symptom summary score. In embodiments, PROSE computes the average of all ratings over a 14-day period. In embodiments, the symptom score is the total number of dysphagia episodes experienced over 14 days. This may also be referred to as the frequency of dysphagia.

[0098] In embodiments, PROSE provides symptom summary ratings, based on the following questions: (i) how difficult, on a scale from 1-10, was it for you to get the food and / or pills down? (ii) what was the worst pain you felt, on a scale from 1-10, when trying to get the food and / or pills down? (iii) What was the worst discomfort you felt, on a scale from 1-10, when trying to get the food / pills down? In embodiments, the PROSE symptom score is the a mean score of any combination of (i), (ii), and (iii). In embodiments, the mean score of (i), (ii), and (iii) is referred to as “episode severity.”

[0099] An episode severity score may be assigned to a single episode of dysphagia. Alternatively or in addition, an episode severity score may be assigned each day as the “daily episode severity score”. The daily episode severity score is the average episode severity score of all episodes of dysphagia that occur on a single day. In embodiments, the daily episode severity score over a fourteen day period is averaged.

[0100] In embodiments, the methods of the disclosure lead to an improvement in the average daily episode severity score over a specific time period. The average daily episode severity score over a specific time period is the sum of the daily episode severity score for each day in which an episode of dysphagia is reported divided by the number of days in the time period that the episodes of dysphagia are reported. The episode severity score is the mean of the PROSE symptom scores (i), (ii), and (iii). In embodiments, the average daily episode severity score is calculated over a time period of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 31 days, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 18 months, or 2 years. In embodiments, the average daily episode severity score is calculated over 14 days. For example, if the average daily episode severity score is calculated over a time period of 14 days and the subject experiences episodes of dysphagia on 12 out of 14 days of the time period, the average daily episode score over the 14 day time period is the sum of daily episode severity score of the 12 days reported divided by 12.

[0101] In embodiments, the methods of the disclosure lead to an improvement in symptom burden. The symptom burden is the average daily episode severity score over a specific time period, including days in which no episodes of dysphagia are reported. As discussed herein, the daily episode severity score is the episode severity score divided by the number of dysphagia episodes in one day. The episode severity score is the mean of the PROSE symptom scores (i), (ii), and (iii), wherein a day with no dysphagia episodes is assigned a daily episode severity score of zero. In embodiments, symptom burden is calculated over a time period of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 31 days, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11weeks, 12 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 18 months, or 2 years. In embodiments, the symptom burden is calculated over 14 days. For example, the symptom burden calculated over a time period of 14 days is the sum of the daily episode score of each of the 14 days divided by 14, wherein a day in which no dysphagia episodes are reported is assigned a daily episode score of 0.

[0102] In embodiments, a daily episode severity score is the episode severity score for the worst episode of dysphagia. The worst episode of dysphagia in a given day has the highest episode severity score. The method to calculate the severity score id described herein.

[0103] In embodiments, the methods of the disclosure lead to an improvement in the score of the worst symptom of dysphagia reported over a particular time period. In embodiments, the worst symptom of dysphagia has the highest PROSE symptom score. For example, if a subject assigns (i) a score of 9, (ii) a score of 5, and (iii) a score of 1, (i) is the worst symptom.

[0104] In embodiments, the PROSE symptom score includes the number of dysphagia episodes. In embodiments, the PROSE symptom score includes the number of dysphagia episodes daily rate of dysphagia episodes. In embodiments, the PROSE symptom score includes the number of dysphagia episodes daily rate of dysphagia episodes, a number of dysphagia-free days. In embodiments, PROSE provides a daily mean composite score (e.g., for all reported incidences of dysphagia) over 14 days, a daily worst composite (e.g., for the reported incidences of dysphagia each day) score over 14 days, a daily worst composite score over 14 days, the number of episodes over 14 days, the daily rate of episodes over 14 days, or the number of dysphagia-free days over 14 days.

[0105] In embodiments, the methods of the disclosure cause the PROSE score (e.g., the episode severity score described above) to improve by about 5 %, or about 10 %, or about 15 %, or about 20 %, or about 25 %, or about 30 %, or about 35 %, or about 40 %, or about 45 %, or about 50 %, or about 55 %, or about 60 %, or about 65 %, or about 70 % , or about 80 %, or about 85 %, or about 90 %, or about 95 %, or about 100 %, or more. In embodiments, the methods of the disclosure cause the number of episodes of dysphagia to decrease as determined by the PROSE instrument. In embodiments, the methods of the disclosure cause the PROSE score to improve by about 0.2, about 0.3, about 0.4, about 0.5, about 0.6, about 0.7, about 0.8, about 0.9, about 1.0, about 1.1, about 1.2, about 1.3, about 1.4, about 1.5, about 1.6, about 1.7, about 1.8, about 1.9, about 2.0, about 2.1, about 2.2, about 2.3, about 2.4, about 2.5, about 2.6, about 2.7, about 2.8, about 2.9,about 3.0, about 3.1, about 3.2, about 3.3, about 3.4, about 3.5, about 3.6, about 3.7, about 3.8, about 3.9, about 4.0, about 4.1, about 4.2, about 4.3, about 4.4, about 4.5, about 4.6, about 4.7, about 4.8, about 4.9, about 5.0, about 5.1, about 5.2, about 5.3, about 5.4, about 5.5, about 5.6, about 5.7, about 5.8, about 5.9, about 6.0, about 6.1, about 6.2, about 6.3, about 6.4, about 6.5, about 6.6, about 6.7, about 6.8, about 6.9, about 7.0, or more, inclusive of all ranges between these values.

[0106] In embodiments, the PROSE instrument is described in International Publication Number WO / 2019 / 165138, the contents of which are incorporated by reference herein in its entirety. The 24-hour diary refers to a device used for recording various events associated with dysphagia (e.g. associated with EoE) at the end of a 24 hour period, i. e. once a day. At the end of a 24 hour period, the patient recalls all the events associated with dysphagia that occurred over the previous 24 hour period, including inter alia, (i) the severity, intensity, duration, pain, discomfort, difficulty, and / or frequency of dysphagia, (ii) type (including dosage form and active agent) and timing of treatment, and (iii) avoidance measures. In embodiments, the patient records entries in the 24-hour diary after the last meal. In embodiments, the patient records entries in the 24-hour diary about 6 p.m, about 6:30 p.m., about 7:00 p.m., about 7:30 p.m., about 8:00 p.m., about 8:30 p.m., about 9:00 p.m., about 9:30 p.m., about 10:00 p.m., about 10:30 p.m., about 11 :00 p.m., or about 12:00 a.m.

[0107] In embodiments, methods of the present disclosure cause an improvement as suggested by the 24-hour diary outcome. U.S. Publication No. 2016 / 0078186 details the 24-hour diary outcome and is incorporated by reference in its entirety for all purposes.

[0108] In embodiments, the methods of the present disclosure cause an improvement in a subject’s EoE Endoscopic Reference score (EREFS). The EREFS identifies the severity of five endoscopic findings: edema, rings, exudates, furrows, and strictures. The EREFS classification system rates the severity of each of the endoscopic findings. The severity of edema is rated on a scale from 0 to 2. The severity of rings is rated from 0 to 3. The severity of exudates is rated from 0 to 2. The severity of furrows is rated from 0 to 2. The severity of strictures is rated from 0 to 1. The absence of a finding corresponds to a score of 0. The presence of a finding corresponds to a score of 1, 2, or 3. A higher score is correlated with higher severity. In embodiments, the composite EREFS score, or the sum of the individual scores, is utilized to indicate the severity of EoE. In embodiments, the inflammatory EREFS score, or the sum of the individual edema, exudate, and furrows score, is utilized to indicate the severity of EoE. In embodiments, a higher inflammatoryor composite EREFS score corresponds to the severity of EoE. In embodiments, the inflammatory or composite EREFS score decreases after treatment with a corticosteroid according to the methods of the disclosure. In embodiments, a EREF responder has a EREFS total score between 0 and 2, inclusive, with no score for any component (edema, exudates, furrows, rings, and strictures) greater than 1 and no worsening from baseline in any component. In embodiments, a EREF total score responder has a EREF total score equal to zero (0). In embodiments, a EREF inflammatory score responder has a EREF inflammatory score equal to zero (0) (defined as the sum of the most severe score for edema, exudates, and furrows) with no worsening from baseline in rings or strictures. In embodiments the inflammatory or composite EREFS score decreases by 0.1 , or about 0.2, or about 0.3, or about 0.4, or about 0.5, or about 0.6, or about 0.7, or about 0.8, or about 0.9, or about 1.0, or about 1.1, or about 1.2, or about 1.3, or about 1.4, or about 1.5, or about 1.6, or about 1.7, or about 1.8, or about 1.9, or about 2.0, or about 2.1, or about 2.2, or about 2.3, or about 2.4, or about 2.5, or about 2.6, or about 2.7, or about 2.8, or about 2.9, or about 3.0, or about 3.1, or about 3.2, or about 3.3, or about 3.4, or about 3.5, or about 3.6, or about 3.7, or about 3.8, or about 3.9, or about 4.0, or about 4.1, or about 4.2, or about 4.3, or about 4.4, or about 4.5, or about 4.6, or about 4.7, or about 4.8, or about 4.9, or about 5.0, or about 5.1, or about 5.2, or about 5.3, or about 5.4, or about 5.5, or about 5.6, or about 5.7, or about 5.8, or about 5.9, or about 6.0, or about 6.1, or about 6.2, or about 6.3, or about 6.4, or about 6.5, or about 6.6, or about 6.7, or about 6.8, or about 6.9, or about 7.0, or about 7.1, or about 7.2, or about 7.3, or about 7.4, or about 7.5, or about 7.6, or about 7.7, or about 7.8, or about 7.9, or about 8.0, or about 8.1, or about 8.2, or about 8.3, or about 8.4, or about 8.5, or about 8.6, or about 8.7, or about 8.8, or about 8.9, or about 9.0, or about 9.1, or about 9.2, or about 9.3, or about 9.4, or about 9.5, or about 9.6, or about 9.7, or about 9.8, or about 9.9, or about 10.0 points, or more, inclusive of all ranges between these values. In embodiments, the EREFS score decreases by 1 %, or 5 %, or 10 %, or 15 %, or 20 %, or 25 %, or 30 %, or 35 %, or 40 %, or 45 %, or 50 %, or 55 %, or 60 %, or 65 %, or 70 %, or 75 %, or 80 %, or 85 %, or 90 %, or 95 % or more, inclusive of all ranges between these values. The following article, incorporated by reference in its entirety herein, describes the EREFS score: Wechsler, Clin Hepatol. 2018 Jul; 16(7): 1056-1063. In embodiments, the subject is a EREF responder after treatment. In embodiments, the subject is a EREF total score responder after treatment. In embodiments, the subject is a EREF inflammatory score responder after treatment.

[0109] In embodiments, the subject’s symptom score is evaluated using the Visual Dysphagia Question (VDQ). The VDQ addresses the severity of dysphagia when consuming food of 8 distinct consistencies. The 8 food consistencies and examples of foods to illustrate those consistencies are: 1) solid meat (such as steak, chicken, turkey, lamb), 2) soft foods (such as pudding, jelly, apple sauce), 3) dry rice or sticky Asian rice, 4) ground meat (hamburger, meatloaf), 5) fresh white untoasted bread or similar foods (such as doughnut, muffin, cake), 6) grits, porridge (oatmeal), or rice pudding, 7) raw fibrous foods (such as apple, carrot, celery), and 8) French fries. The degree of perceived difficulties when eating a given food consistency is graded between 0 for ‘No difficulties’ and 3 for ‘Severe difficulties’. A VDQ composite score is calculated using the individual grades for a given food consistency. The VDQ composite score is the sum of the grades for each food consistency divided by the maximum sum of individual grades for each food consistency that could be attained. The maximum sum of grades depends on the number of food consistencies consumed by a subject in a given recall period. In embodiments, the VDQ composite score is improved after treating according to the methods of the disclosure. An improvement in the VDQ composite score is a decrease in VDQ composite score. In embodiments, the VDQ composite score is improved by between about 1 and about 24 points, for example, about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, or about 24 points.

[0110] In embodiments, outcomes of the methods of the disclosure are evaluated using the EoE Activity Index (EEsAI) avoidance modification, and slow swallowing (AMS) score. In embodiments the EEsAI is improved by about 2 to 15 points. In embodiments, the EEsAI score is improved by about 2.0, or about 2.1, or about 2.2, or about 2.3, or about 2.4, or about 2.5, or about 2.6, or about 2.7, or about 2.8, or about 2.9, or about 3.0, or about 3.1, or about 3.2, or about 3.3, or about 3.4, or about 3.5, or about 3.6, or about 3.7, or about 3.8, or about 3.9, or about 4.0, or about 4.1 , or about 4.2, or about 4.3, or about 4.4, or about 4.5, or about 4.6, or about 4.7, or about 4.8, or about 4.9, or about 5.0, or about 5.1, or about 5.2, or about 5.3, or about 5.4, or about 5.5, or about 5.6, or about 5.7, or about 5.8, or about 5.9, or about 6.0, or about 6.1, or about 6.2, or about 6.3, or about 6.4, or about 6.5, or about 6.6, or about 6.7, or about 6.8, or about 6.9, or about 7.0, or about 7.1, or about 7.2, or about 7.3, or about 7.4, or about 7.5, or about 7.6, or about 7.7, or about 7.8, or about 7.9, or about 8.0, or about 8.1, or about 8.2, or about 8.3, or about 8.4, orabout 8.5, or about 8.6, or about 8.7, or about 8.8, or about 8.9, or about 9.0, or about 9.1, or about 9.2, or about 9.3, or about 9.4, or about 9.5, or about 9.6, or about 9.7, or about 9.8, or about 9.9, or about 10.0, or about 10.1, or about 10.2, or about 10.3, or about 10.4, or about 10.5, or about10.6, or about 10.7, or about 10.8, or about 10.9, or about 11.0, or about 11.1, or about 11.2, or about 11.3, or about 11.4, or about 11.5, or about 11.6, or about 11.7, or about 11.8, or about 11.9, or about 12.0, or about 12.1, or about 12.2, or about 12.3, or about 12.4, or about 12.5, or about12.6, or about 12.7, or about 12.8, or about 12.9, or about 13.0, or about 13.1, or about 13.2, or about 13.3, or about 13.4, or about 13.5, or about 13.6, or about 13.7, or about 13.8, or about 13.9, or about 14.0, or about 14.1, or about 14.2, or about 14.3, or about 14.4, or about 14.5, or about14.6, or about 14.7, or about 14.8, or about 14.9, or about 15 points, inclusive of all ranges between these values.

[0111] In embodiments of the disclosure, the global EoE score is utilized to evaluate the outcomes of the methods of the disclosure. In embodiments, the EoE score is improved by 1 point to 4 points. In embodiments, the EoE score is improved by about 1 point, or about 2 points, or about 3 points, or about 4 points. In embodiments, the EoE score is improved by 5 %, or about 10 %, or about 15 %, or about 20 %, or about 25 %, or about 30 %, or about 35 %, or about 40 %, or about 45 %, or about 50 %, or about 55 %, or about 60 %, or about 65 %, or about 70 %, or about 75 %, or about 80 %, or about 85 %, or about 90 %, or about 95 %, or about 100 %, or about 125 %, or about 150 %, or about 175 %, or about 200 %, or about 225 %, or about 250 %, or about 275 %, or about 300 % or more, inclusive of all ranges between these values.

[0112] In embodiments, the adult eosinophilic oesophagitis quality of life questionnaire (EoE- QoL-A) is utilized to evaluate the outcomes of the methods of the disclosure. The EoE-QoL-A) provides a measure of health-related quality of life. The EoE-QoL-A is a self-reported questionnaire designed to assess disease-specific health-related quality of life in adults with EoE. Questions are designed to evaluate established domains of health-related quality of life, including social functioning, emotional functioning, and disease impact on daily life experiences. The EoE- QoL-A includes 47 questions on a five point scale. Higher scores indicate a better quality of life. In embodiments, the methods of the present disclosure result in an improvement in the EoE-QoL- A. In embodiments, the EoE-QoL-A score is improved by about 1 to about 3 points.

[0113] In embodiments, the patient global impression of severity (PGIS) is utilized to evaluate the outcomes of the methods of the disclosure. The PGIS is a global index that may be used to rate theseverity of EoE. The PGIS is measured on a scale of 1 to 7. A score of 1 corresponds to normal, and a score of 7 corresponds to extremely ill. A score of 4 corresponds to moderately ill. In embodiments, the methods of the disclosure result in a reduction in PGIS score. In embodiments, the PGIS score shifts to improvement by about 1 to 5 severity categories (e.g., about 1, 2, 3, 4 or 5 categories). In embodiments, the PGIS is reduced by 1 point, or 2 points, or 3 points, or 4 points, or 5 points. In embodiments, the PGIC is reduced by about 5 %, or about 10 %, or about 15 %, or about 20 %, or about 25 %, or about 30 %, or about 35 %, or about 40 %, or about 45 %, or about 50 %, or about 55 %, or about 60 %, or about 65 %, or about 70 %, or about 75 %, or about 80 %, or about 85 %, or about 90 %, or about 95 %, or about 100 %, , inclusive of all ranges between these values.

[0114] In embodiments, the patient global impression of change (PGIC) is utilized to evaluate the outcomes of the methods of the disclosure. The PGIC is a global index that may be utilized to assess an improvement or a decline in clinical status. The PGIC is measured on a scale of 1 to 7. A score of 1 corresponds to very much improved, and a score of 7 corresponds to very much worse. A score of 4 corresponds to no change in a subject’s symptoms. In embodiments, the methods of the disclosure result in a reduction in PGIC score. In embodiments, the PGIC is reduced by 1 point, or 2 points, or 3 points, or 4 points, or 5 points, or 6 points, inclusive of all ranges between these values. In embodiments, the PGIC is reduced by about 5 %, or about 10 %, or about 15 %, or about 20 %, or about 25 %, or about 30 %, or about 35 %, or about 40 %, or about 45 %, or about 50 %, or about 55 %, or about 60 %, or about 65 %, or about 70 %, or about 75 %, or about 80 %, or about 85 %, or about 90 %, or about 95 %, or about 100 %, , inclusive of all ranges between these values.

[0115] In embodiments, a reduction in eosinophil count is associated with an improvement in EoE. In embodiments, the methods of the disclosure lead to a reduction in a subject’s eosinophil count compared to the subject’s baseline eosinophil levels. In embodiments, the methods of the disclosure lead to an eosinophil count that is reduced to no more than 6 eosinophils per high power field (hpf). In embodiments, the methods of the disclosure lead to an eosinophil count that is reduced to no more than 5 eosinophils per high power field (hpf), or 4 eosinophils per high power field (hpf), or 3 eosinophils per high power field (hpf), or 2 eosinophils per high power field (hpf), or 1 eosinophils per high power field (hpf). In embodiments, the methods of the disclosure involve measurement of the eosinophil count in the distal portion of the esophagus, the proximal portion31of the esophagus, or both. In embodiments, the methods of the disclosure lead to an eosinophil count in the distal portion of the esophagus of no more than 6 eosinophils per hpf In embodiments, the methods of the disclosure lead to an eosinophil count in the distal portion of esophagus that is reduced to no more than 5 eosinophils per high power field (hpf), or 4 eosinophils per high power field (hpf), or 3 eosinophils per high power field (hpf), or 2 eosinophils per high power field (hpf), or 1 eosinophils per high power field (hpf). In embodiments, the methods of the disclosure lead to an eosinophil count in the proximal portion of the esophagus of no more than 6 eosinophils per hpf. In embodiments, the methods of the disclosure lead to an eosinophil count in the proximal portion of esophagus that is reduced to no more than 5 eosinophils per high power field (hpf), or 4 eosinophils per high power field (hpf), or 3 eosinophils per high power field (hpf), or 2 eosinophils per high power field (hpf), or 1 eosinophils per high power field (hpf).

[0116] In some embodiments that may be combined with any other embodiments described herein, the first and the second samples are the same. In some embodiments, the first and the second samples are from the same type of tissue. In some embodiments, one or both of the first and second samples is / are from a gastric or duodenal biopsy. In some embodiments, one or both of the first and second samples is / are from an esophago-gastro-duodenoscopy (EGD) with biopsy. In some embodiments, the first sample has at least three high-power fields (HPFs) that each have a mast cell count of 30 or more mast cells per HPF. In some embodiments, the first sample has at least three high-power fields (HPFs) that each have a mast cell count of 25 or more mast cells per HPF. In some embodiments, the first sample has at least three high-power fields (HPFs) that each have a mast cell count of 20 or more mast cells per HPF. In some embodiments, the first sample has at least two high-power fields (HPFs) that each have a mast cell count of 30 or more mast cells per HPF. In some embodiments, the first sample has at least two high-power fields (HPFs) that each have a mast cell count of 25 or more mast cells per HPF. In some embodiments, the first sample has at least two high-power fields (HPFs) that each have a mast cell count of 20 or more mast cells per HPF. In some embodiments, the first sample has at least one high-power field (HPF) that has a mast cell count of 30 or more mast cells. In some embodiments, the first sample has at least one high-power field (HPF) that has a mast cell count of 25 or more mast cells. In some embodiments, the first sample has at least one high-power field (HPF) that has a mast cell count of 20 or more mast cells. In some embodiments, mast cells are detected by immunohistochemical (IHC) staining for tryptase, chymase, CD117 (c-kit), or IgE receptor. In embodiments, mast cellsare detected by metachromatic stain selected from Romanowsky combinations, toluidine blue, and Alcian blue. In embodiments, the number of mast cells in a sample is counted by hematoxylin and eosin (H&E) staining. In some embodiments, the second sample has one or more HPFs that each have an eosinophil count of less than 30 eosinophils per HPF. In some embodiments, the second sample is obtained from the gastric mucosa of the individual, and the second sample does not have at least five HPFs that each have an eosinophil count of 30 or more eosinophils per HPF. In some embodiments, the second sample is obtained from the duodenal mucosa of the individual, and the second sample does not have at least three HPFs that each have an eosinophil count of 30 or more eosinophils per HPF. In some embodiments, the number of mast cells in the first sample is detected 45 days or less prior to administration of the composition.

[0117] In some embodiments, one or more of a number, activity, or location of mast cells in a sample obtained from the esophageal mucosa of the individual is reduced after administration of the composition as compared to a baseline level before administration of the composition. In some embodiments, prior to administration of the composition, the individual has failed or is not adequately controlled by one or more standard-of-care treatments for esophagitis. In some embodiments, the one or more symptom(s) of esophagitis in the individual are reduced after administration of the composition as compared to a baseline level before administration of the composition. In some embodiments, the one or more symptom(s) of esophagitis in the individual are reduced by at least 50%, at least 55%, at least 60%, or at least 65% after administration of the composition as compared to a baseline level before administration of the composition. In some embodiments, one or more of heartburn, nausea, dysphagia / difficulty swallowing, vomiting, abdominal pain, cough, food impaction, early satiety, loss of appetite, chest pain, feeding intolerance or refusal, and gastroesophageal reflux in the individual are reduced after administration of the composition as compared to a baseline level before administration of the composition.

[0118] In some embodiments, mast cells are detected by immunohistochemical (IHC) staining for tryptase, chymase, CD117, or IgE receptor (Ribatti, Int Arch Allergy Immunol (2018) 176 (1): 55- 60; Nishida, et al., Sci Rep. 2018 Mar 15;8(1):4656). In embodiments, mast cells are detected by metachromatic stain selected from Romanowsky combinations, toluidine blue, and Alcian blue (Wright, Giemsa, May-Grtinwald Giemsa, and Leishma; Ribatti, Int Arch Allergy Immunol (2018) 176 (1): 55-60). In embodiments, the number of mast cells in a sample is counted by hematoxylinand eosin (H&E) staining. In some embodiments, the number of mast cells in the first sample is detected 45 days or less prior to administration of the composition. In some embodiments, the individual has had, or has previously been diagnosed with, eosinophilic colitis, and the individual has one or more symptoms of eosinophilic colitis without elevated eosinophils. In some embodiments, one or both of a number or activity of mast cells in a sample obtained from the colonic mucosa of the individual are reduced after administration of the composition as compared to a baseline level before administration of the composition. In some embodiments, prior to administration of the composition, the individual has failed or is not adequately controlled by one or more standard-of-care treatments for colitis. In some embodiments, the one or more symptom(s) of colitis in the individual are reduced after administration of the composition as compared to a baseline level before administration of the composition. In some embodiments, the one or more symptom(s) of colitis in the individual are reduced by at least 50%, at least 55%, at least 60%, or at least 65% after administration of the composition as compared to a baseline level before administration of the composition.

[0119] In embodiments, a symptom of EoE is dysphagia. In embodiments, the methods of the disclosure lead to a decreased number of dysphagia episodes compared to a subject that is administered the corticosteroid twice daily. In embodiments, the methods of the disclosure lead to an increased number of dysphagia-free days compared to a subject that is administered the corticosteroid twice daily. In embodiments, treating comprises reducing the number of dysphagia episodes relative to baseline. In embodiments, the number of dysphagia episodes is reduced by 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 or more relative to baseline. In embodiments, treating comprises the subject experiencing no episodes of dysphagia. In embodiments, treating comprises the subject experiencing no episodes of dysphagia in a 14 day period. In embodiments, treating comprises the subject experiencing no episodes of dysphagia in 14 consecutive days prior to week 24.Numbered Embodiments of the Disclosure

[0120] In addition to the disclosure above, the Examples below, and the appended claims, the disclosure sets forth the following numbered embodiments.1. A method of reducing mast cell count and / or activity in a subject in need thereof, comprising topically administering a corticosteroid to the subject’s esophageal tissue, wherein after administering the corticosteroid, the subject has a peak post-treatment mast cell count of no more than 6 mast cells per high power field (HPF) in at least one biopsy of the esophagus.2. The method of embodiment 1, further comprising obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count before topically administering the corticosteroid to the subject’s esophageal tissue.3. The method of embodiment 1 or 2, further comprising obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count after topically administering the corticosteroid to the subject’s esophageal tissue for a period of time.4. A method of treating eosinophilic esophagitis (EoE) in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 12 weeks, wherein the subject has a peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus.5. A method of treating EoE in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 24 weeks, wherein the treatment leads to a reduction in a peak post-treatment mast cell count per HPF in at least one biopsy of the esophagus of the subject by at least about 60% at week 24 compared to baseline.6. The method of any one of embodiments 1-5, wherein the mast cell count is measured in the distal portion of the esophagus, the proximal portion of the esophagus, or both.7. The method of embodiment 6, wherein the peak post-treatment mast cell count in the distal portion of the esophagus is no more than 6 mast cells per HPF in at least one biopsy.8. The method of embodiment 7, wherein the peak post-treatment mast cell count in the proximal portion of the esophagus is no more than 6 mast cells per HPF in at least one biopsy.9. The method of any one of embodiments 1-8, wherein the subject has a peak pretreatment mast cell count of 10 or more mast cells per HPF in at least one biopsy of the esophagus.10. The method of any one of embodiments 1-8, wherein the subject has a peak pretreatment mast cell count of 15 or more mast cells per HPF in at least one biopsy of the esophagus.11. The method of any one of embodiments 1-10, wherein the subject has a peak post-treatment mast cell count of no more than 5 mast cells per HPF in at least one biopsy of the esophagus.12. The method of any one of embodiments 1-10, wherein the subject has a peak post-treatment mast cell count of no more than 4 mast cells per HPF in at least one biopsy of the esophagus.13. The method of any one of embodiments 1-10, wherein the subject has a peak post-treatment mast cell count of no more than 3 mast cells per HPF in at least one biopsy of the esophagus.14. The method of any one of embodiments 1-10, wherein the subject has a peak post-treatment mast cell count of no more than 2 mast cells per HPF in at least one biopsy of the esophagus.15. The method of any one of embodiments 1 -8, wherein the subject has a peak posttreatment mast cell count of no more than 1 mast cells per HPF in at least one biopsy of the esophagus.16. The method of embodiments 1-15, wherein the method leads to a reduction in peak post-treatment mast cell count by at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98%relative to baseline.17. The method of any one of embodiments 1-16, wherein the method leads to a reduction in transient mast cell counts by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98%relative to baseline.18. The method of any one of embodiments 1-17, wherein the method leads to a reduction in transient mast cell counts by at least 1 transient mast cell per HPF, at least 2 transient mast cells per HPF, at least 3 transient mast cells per HPF, at least 4 transient mast cells per HPF, at least 5 transient masts cell per HPF, at least 6 transient mast cells per HPF, at least 7 transient mast cells per HPF, at least 8 transient mast cells per HPF, at least 9 transient masts cell per HPF, or at least 10 transient masts cell per HPF relative to baseline.19. The method of any one of embodiments 1-18, wherein the method leads to a reduction in persistent mast cell counts by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 98% relative to baseline.20. The method of any one of embodiments 1-19, wherein the method leads to a reduction in persistent mast cell counts by at least 1 persistent mast cell per HPF, at least 2 persistent mast cells per HPF, at least 3 persistent mast cells per HPF, at least 4 persistent mast cells per HPF, at least 5 persistent masts cell per HPF, at least 6 persistent mast cells per HPF, atleast 7 persistent mast cells per HPF, at least 8 persistent mast cells per HPF, at least 9 persistent masts cell per HPF, or at least 10 persistent masts cell per HPF relative to baseline.21. The method of any one of embodiments 1-20, wherein the method leads to a reduction in proliferative mast cell counts by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 98% relative to baseline.22. The method of any one of embodiments 1-21, wherein the method leads to a reduction in proliferative mast cell counts by at least 1 proliferative mast cell per HPF, at least 2 proliferative mast cells per HPF, at least 3 proliferative mast cells per HPF, at least 4 proliferative mast cells per HPF, at least 5 proliferative masts cell per HPF, at least 6 proliferative mast cells per HPF, at least 7 proliferative mast cells per HPF, at least 8 proliferative mast cells per HPF, at least 9 proliferative masts cell per HPF, or at least 10 proliferative masts cell per HPF relative to baseline.23. The method of any one of embodiments 1-22, wherein the method leads to mucosal normalization.24. The method of any one of embodiments 1-23, wherein the method leads to absence of one or more of eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, or fibrosis.25. The method embodiment 24, wherein the method leads to absence of eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis.26. The method of any of the preceding embodiments, wherein the subject shows an improvement in at least one of the following outcomes:(i) at least one symptom score measured using a patient reported outcome symptom evaluation (PROSE) instrument;(ii) EoE Endoscopic Reference (EREF) score;(iii) EoE Activity Index (EEsAI) avoidance, modification, and slow swallowing (AMS) score;(iv) Global EoE score;(v) Patient global impression of severity (PGIS); and(vi) Patient global impression of change (PGIC).27. The method of any of the preceding embodiments, wherein 1.5 mg or 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, is administered.28. The method of any of the preceding embodiments, wherein 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, is administered.29. The method of any of the preceding embodiments, wherein fluticasone propionate or the corticosteroid is administered at bedtime or at nighttime.30. The method of any of the preceding embodiments, wherein fluticasone propionate or the corticosteroid is administered while the subject is lying down or immediately prior to the subject lying down.31. The method of any of the preceding embodiments, wherein the corticosteroid is administered once daily.32. The method of embodiment 26, wherein the symptom score measured using PROSE comprises:(i) on a scale ranging from 0 to 10, a difficulty getting food down;(ii) on a scale ranging from 0 to 10, a worst discomfort with food;(iii) on a scale ranging from 0 to 10, a worst pain with food;(iv) a mean score of any combination of (i), (ii), and (iii);(v) a number of dysphagia episodes;(vi) a daily rate of dysphagia episodes; or(vii) a number of dysphagia-free days.33. The method of embodiment 32, wherein the mean score is the mean of (i), (ii), and (iii).34. The method of embodiment 32, wherein the mean score is the mean of (i), (ii), and (iii) calculated from one or more episodes of dysphagia over a period of time.35. The method of embodiment 32, wherein if the subject experiences more than one episode of dysphagia, the mean score is calculated for the worst episode or worst symptoms of dysphagia.36. The method of embodiment 32, wherein the symptom score is:(a) a daily mean of (i), (ii), and (iii) over a 14 day period;(b) a mean score of (i), (ii), and (iii) for the worst episode per day of dysphagia over a 14 day period;(c) a score for the worst symptom of dysphagia over a 14 day period;(d) a number of dysphagia episodes;(e) a daily rate of dysphagia episodes; or(f) a number of dysphagia-free days.37. The method of any of embodiments 32-36, wherein at least one symptom score is improved by 0.5 to 4 points.38. The method of any of the preceding embodiments, wherein the symptom score, the mean score, the worst episode score, or the worst symptom score is determined using data from 2 weeks of entries immediately prior to Week 12 and Week 26.39. The method of any of embodiments 26-38, wherein the EREF score is improved by about 0.3 to 1.5 points.40. The method of embodiment 39, wherein the subject is a EREF responder after treatment.4E The method of embodiment 39, wherein the subject is a EREF total score responder after treatment.42. The method of embodiment 39, wherein the subject is a EREF inflammatory score responder after treatment.43. The method of any of any of embodiments 26-42, wherein the Global EoE score is improved by about 1 to 4 points.44. The method of any of embodiments 26-42, wherein the PGIS score shifts to improvement by about 1 to 5 severity categories.45. The method of any of embodiments 26-42, wherein the EEsAI score is improved by about 2 to 15 points.46. The method of any of embodiments 26-42, wherein the subject further shows improvement in Eosinophilic Esophagitis Quality of Life Questionnaire (EoO-QoL-A).47. The method of embodiment 46, wherein the EoO-QoL-A score is improved by about 1 to 3 points.48. The method of any of the preceding embodiments, wherein eosinophil count in the subject’s esophagus are reduced compared to the subject’s baseline eosinophil levels as measured in at least one biopsy of the esophagus.49. The method of embodiment 48, wherein the eosinophil count are reduced to no more than 6 eosinophils per high power field (HPF) as measured in at least one biopsy of the esophagus.50. The method of embodiment 49, wherein the eosinophil count are measured in the distal portion of the esophagus, the proximal portion of the esophagus, or both.51. The method of embodiment 48, wherein eosinophil count in the distal portion of the esophagus is no more than 6 eosinophils per HPF in at least one biopsy.52. The method of embodiment 49, wherein eosinophil count in the proximal portion of the esophagus is no more than 6 eosinophils per HPF in at least one biopsy.53. The method of any of any of embodiments 36-52, wherein (a) and (b) are measured at week 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and / or 12.54. The method of embodiment 53, wherein (a) and (b) are measured again at week 24 and / or week 52.55. The method of any of the preceding embodiments, wherein fluticasone propionate or the corticosteroid is administered for about 12 weeks to at least one year.56. The method of any of the preceding embodiments, wherein the corticosteroid is formulated as a solid composition.57. The method of embodiment 56, wherein the solid composition is in the form of a gel, lozenge, lollipop, effervescent tablet, powder, granules, an orally disintegrating composition or an orally dispersing composition.58. The method of embodiment 57, wherein the orally disintegrating composition is a tablet, wafer, film, effervescent, or lyophilized matrix.59. The method of embodiment 57, wherein the orally disintegrating composition is a tablet or effervescent.60. The method of any one of the preceding embodiments, wherein the reduction in the mast cell count correlates with the reduction in the eosinophil count in at least one biopsy of the esophagus.61. The method of embodiment 60, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF and the post-treatment peak eosinophil count of no more than 6 eosinophils per HPF, wherein the agreement is at least about 80%, about 85%, about 90%, or about 95%.62. The method of embodiment 61 , wherein the agreement is at least about 85%.63. The method of any one of the preceding embodiments, wherein the reduction in the post-treatment mast cell count correlates with mucosal healing in at least one biopsy of the esophagus.64. The method of embodiment 63, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF and mucosal normalization, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.65. The method of embodiment 64, wherein the agreement is at least about 70%.66. The method of any one of embodiments 1-65, wherein the method leads to a reduction in episodes of dysphagia.67. The method of any one of embodiments 1-65, wherein, after administering the corticosteroid, the subject experiences no episodes of dysphagia over a 14 day period.68. The method of any one of embodiments 1-65, wherein, after administering the corticosteroid, the subject experiences no dysphagia days over a 18 day period.69. A method of optimizing therapy in a subject having eosinophilic esophagitis (EoE) and receiving treatment of a corticosteroid comprising(a) topically administering about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, to the subject’s esophageal tissue or orally administering to the subject once daily for a treatment period;(b) determining at several points in time a level of at least one mast cell-associated biomarker present in a sample from the subject, wherein the sample is selected from the group consisting of a biopsy of the esophagus, a serum sample, a blood sample, and a urine sample, wherein the biomarker is indicative of the severity of EoE in the subject; and(c) adjusting the treatment period based on the level of the at least one mast cell associated biomarker.70. The method of embodiment 69, wherein the treatment comprises daily administration of 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid for about 12 weeks to at least one year.71. The method of embodiments 69 or 70, wherein the level of the biomarker present in the sample is determined prior to the treatment and one or more times after the treatment.72. The method of embodiment 71, wherein the level of the biomarker present in the sample is determined about every 4 weeks or about every 12 weeks post the treatment.73. The method of any one of embodiments 69-72, wherein a reduction in the posttreatment mast cell count correlates with a reduction in the post-treatment eosinophil count in at least one biopsy of the esophagus over the treatment period.74. The method of embodiment 73, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF and the post-treatment eosinophil count of no more than 6 eosinophils per HPF, wherein the agreement is at least about 80%, about 85%, about 90%, or about 95%.75. The method of embodiment 74, wherein the agreement is at least about 85%.76. The method of any one of embodiments 69-75, wherein a reduction in the posttreatment mast cell count correlates with mucosal healing in at least one biopsy of the esophagus over the treatment period.77. The method of embodiment 76, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF and mucosal normalization, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.78. The method of embodiments 77, wherein the agreement is at least about 70%.79. The method of any of embodiments 69-78, wherein a reduction in the mast cell count correlates with an improved symptom score of EoE.80. The method of embodiment 79, wherein the symptom score comprises:(i) at least one symptom score measured using a patient reported outcome symptom evaluation (PROSE) instrument;(ii) EoE Endoscopic Reference (EREF) score;(iii) EoE Activity Index (EEsAI) avoidance, modification, and slow swallowing (AMS) score;(iv) Global EoE score;(v) Patient global impression of severity (PGIS); and(vi) Patient global impression of change (PGIC).81. The method of embodiment 74, wherein the symptom score using PROSE comprises:(i) on a scale ranging from 0 to 10, a difficulty getting food down;(ii) on a scale ranging from 0 to 10, a worst discomfort with food;(iii) on a scale ranging from 0 to 10, a worst pain with food;(iv) a mean score of any combination of (i), (ii), and (iii);(v) a number of dysphagia episodes;(vi) a daily rate of dysphagia episodes; or(vil) a number of dysphagia-free days.82. The method of embodiment 81, wherein the mean score is the mean of (i), (ii), and (iii).83. The method of embodiment 81, wherein the mean score is the mean of (i), (ii), and (iii) calculated from one or more episodes of dysphagia over a period of time.84. The method of embodiment 81, wherein if the subject experiences more than one episode of dysphagia, the mean score is calculated for the worst episode or worst symptoms of dysphagia.85. The method of embodiment 81, wherein the symptom score is:(a) a daily mean of (i), (ii), and (iii) over a 14 day period;(b) a mean score of (i), (ii), and (iii) for the worst episode per day of dysphagia over a 14 day period;(c) a score for the worst symptom of dysphagia over a 14 day period;(d) a number of dysphagia episodes;(e) a daily rate of dysphagia episodes; or(f) a number of dysphagia-free days.86. The method of any of embodiments 80-85, wherein at least one symptom score is improved by 0.5 to 4 points.87. The method of any of embodiments 80-86, wherein the symptom score, the mean score, the worst episode score, or the worst symptom score is determined using data from 2 weeks of entries immediately prior to Week 12 and Week 24.88. The method of any of embodiments 80-86, wherein the EREFS score is improved by about 0.3 to E 5 points.89. The method of any of embodiments 80-86, wherein the Global EoE score is improved by about 1 to 4 points.90. The method of any of embodiments 80-86, wherein the PGIS score shifts to improvement by about 1 to 5 severity categories.91. The method of any of the preceding embodiments, wherein the EEsAI score is improved by about 2 to 15 points.92. The method of any of embodiments 80-86, wherein the subject further shows improvement in Eosinophilic Esophagitis Quality of Life Questionnaire (EoO-QoL-A).93. The method of embodiment 92, wherein the EoO-QoL-A score is improved by about 1 to 3 points.94. The method of any one of embodiments 69-93, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus and an improved symptom score, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.95. The method of any one of embodiments 69-94, wherein adjusting the treatment period based on the level of the at least one mast cell associated biomarker comprises discontinuing the administration if the peak mast cell count in at least one biopsy of the esophagus is no more than 6 mast cells per HPF.96. A method of achieving an EREF responder, comprising topically administering a corticosteroid to the subject’s esophageal tissue, wherein the EREF responder is defined as totalscore between 0 and 2, inclusive, with no score for any component (edema, exudates, furrows, rings, and strictures) greater than 1 and no worsening from baseline in any component.97. A method of achieving zero episodes of dysphagia over 14 consecutive days in a subject, comprising topically administering a corticosteroid to the subject’s esophageal tissue.98. The method of embodiment 97, wherein the subject has EoE.99. The method of any one of embodiments 96-98, the method further comprising the method of any one of embodiment 1-95.EXAMPLESEXAMPLE 1. A pilot study on mast cell levels in subjects with EoE

[0121] The pilot study aimed to assess the relationship between the mast cell count and mucosa healing in subjects with eosinophilic esophagitis. The subjects were selected from a phase III clinical trial (i.e., study SP-1011-003) after completing the study.

[0122] Study SP-1011-003 was a Phase III, randomised, double-blind, placebo-controlled, and maintenance study of APT-1011 in subjects (>18 and <75 years of age) with EoE. APT- 1011 is an orally disintegrating tablet (ODT) formulation of fluticasone propionate (FP). APT- 1011 is expected to offer the following advantages for subjects with EoE:(a) Oral formulations are generally more acceptable and more reliable in terms of accurate dose administration. Currently, the only available pharmaceutical form of FP is an MDI approved for the treatment of asthma that is sprayed into the mouth instead of being inhaled and then swallowed by the patient.(b) Oral administration of APT-1011 has very low bioavailability due to the extensive first-pass metabolism in the liver, particularly when compared with alternative corticosteroid products such as budesonide. As such, the potential for systemic corticosteroid toxicity remains low, while offering a more potent topical effect compared to budesonide on a mg to mg basis.

[0123] The Phase III study was designed as follows (FIG. 1).(a) Screening: Subjects with a confirmed diagnosis or presumptive diagnosis of EoE were selected for the study. An EoE diagnosis was confirmed by symptoms and histology.(b) 4 week single-blind placebo run in / baseline symptom assessment: To assess baseline symptoms, all subjects received a placebo hora somni (before sleep; HS) (at bedtime) and were blinded to study drug during the run-in phase of screening(c) Part A (induction) (studies the effect of APT- 1011 over 12 weeks): Subjects that entered Part A of the study had evidence of EoE as defined by >15 peak eosinophils / HPF. At least five to six biopsies should have been taken including both proximal and distal specimens. The subjects must have reported > 6 episodes of dysphagia in the 14 days prior to baseline (via Patient Reported Outcome Symptoms for EoE [PROSE™]). The subjects must have completed the daily diary on at least 11 out of the 14 days during the 2- week Baseline Symptom Assessment.(d) Part B (maintenance) studies the effect of use of APT-1011 to 52 weeks.

[0124] Subjects that participated in Part A studies were randomized and administered a treatment selected from:(a) 3 mg HS: 3 mg at bedtime; and(b) Placebo: Placebo at bedtime.

[0125] During Part A (Induction, Day 1 to Week 12), 143 subjects received their randomized treatment (46 treated with placebo and 97 received APT-1011 3 mg HS) for 12 weeks. At Week 12, the subjects underwent a response assessment, including an EsophagoGastroDuodenoscopy (EGD) to assess endoscopic and histologic status.

[0126] 20 subjects were selected from the SP-1011-003 study for histological analysis on mast cell levels and mucosal healing. 19 subjects received ATP- 1011 and were histological responders at week 12. Histologic responders were those who had <6 peak eosinophils / HPF after assessing at least 5 to 6 biopsies from the proximal and distal oesophagus (approximately 3 each) where the HPF area was 235 square microns (40 magnification lens with a 22 mm ocular).

[0127] Week 12 oesophageal biopsy samples were further processed and evaluated post-hoc for mast cell (me) counts, mast cell remission (defined in the pilot study as peak me < 6 mc / hpf) and mucosal normalization (defined in the pilot study as absence of features documented by central histology lab including eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis). The analysis on the agreement between eosinophilic remission (<6 peak eosinophils / HPF) and mast cell remission (<6 peak mc / HPF), between eosinophilic remission and mucosal normalization, and between mast cell remission and mucosal normalization was conducted. The results were provided in TABLES 4-6.

[0128] TABLE 4 provides the numbers and percentages of the subjects who had eosinophilic remission or not and who had mast cell remission or not, respectively.

[0129] TABLE 5 provides the numbers and percentages of the subjects who had eosinophilic remission or not and who had mucosal normalization or not, respectively.

[0130] TABLE 6 provides the numbers and percentages of the subjects who had mast cell remission or not and who had mucosal normalization or not, respectively.

[0131] The analysis revealed that 85% of subjects displayed both eosinophilic and mast cell remission, and although agreement could not be calculated these findings indicate a strong relationship between remission of eosinophils and remission of mast cells as seen in esophageal biopsies after 12 weeks of APT-1011 treatment (Table 4). 65% of subjects exhibited both eosinophilic remission and mucosal normalization, indicating a moderate agreement (Table 5).Similarly, 70% of subjects showed both mast cell remission and mucosal normalization, also indicating a moderate agreement (Table 6).

[0132] These preliminary data indicate that both eosinophilic and mast cell remission are indicators of esophageal mucosal normalization.EXAMPLE 2. A clinical study on efficacy of fluticasone propionate in reducing mast cells in subjects with EoE

[0133] This study aims to evaluate the efficacy of fluticasone propionate in reducing mast cells in subjects with EoE. This study will be a double-blind, randomized, placebo-controlled clinical trial to examine APT-1011 in subjects (>18 and <75 years of age) with EoE. The subjects will receive one daily dose of 3 mg APT-1011 at bedtime for about 12 to 52 weeks (e.g., about 12 weeks, about 24 weeks, about 36 weeks, about 48 weeks, about 52 weeks, including all values and ranges therein). The pre-treatment baselines will be conducted 1 day, or 2 days, or 3 days, or 4 days, or 5 days, 6 days, or 1 week, or 2 week, or 3 week, or 4 week, or 5 weeks, or 6 weeks prior to initiation of treatment and the outcome measurements will be conducted about every 4 week or about every 12 weeks post the treatment.

[0134] The outcome measurements will include the following:• Pre-treatment (baseline) and post-treatment mast cell count in at least one mucosal biopsy• Pre-treatment and post-treatment cell count of transient mast cells, persistent mast cells and / or proliferative mast cells.• Pre-treatment and post-treatment mucosal histological features (absence or presence of eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis)• Pre-treatment and post-treatment EoE symptom assessment• Pre-treatment and post-treatment eosinophil count

[0135] It’s expected that a reduction in the mast cell count correlates with a reduction in the eosinophil count and mucosal healing in at least one mucosal biopsy over the course of EoE. It is also expected that the peak post-treatment mast cell count of no more than 6 mast cells per HPF inat least one mucosa biopsy correlates with mucosal normalization. Further, a reduction in the mast cell count correlates with an improved symptom score of EoE.EXAMPLE 3. A clinical study on efficacy of fluticasone propionate in reducing mast cells in subjects with EoE

[0136] This study aims to evaluate the efficacy of fluticasone propionate in reducing mast cells in subjects with EoE and achieving zero episodes of dysphagia over 14 consecutive days (complete response).

[0137] In a post-hoc analysis of 143 subjects randomized to 3 mg APT-1011 (97 subjects) or placebo (46 subjects) at bedtime for 12 weeks, dysphagia was measured using an electronic daily diary. All subjects had at least 4 dysphagia days over 14 consecutive days at baseline.

[0138] As compared to placebo, APT- 1011 led to more frequent complete response (zero episodes of dysphagia over 14 consecutive days) (TABLE 7). Amongst subjects with complete symptom response, histologic response (<6 eosinophilic count per HPF) was only seen in subjects receiving APT-1011 (TABLE 8). These data indicate that the depth of symptom resolution with APT-1011 corresponds with histologic response.

[0139] The mast cell count for complete responders and histological responders will be evaluated. It’s expected that a reduction in eosinophil count (histological response) and a reduction in dysphagia (symptomatic response) corresponds with a reduction in mast cell count.EXAMPLE 4. A clinical study on efficacy of fluticasone propionate in reducing mast cells in subjects with EoE

[0140] This study aims to evaluate the efficacy of fluticasone propionate in reducing mast cells in subjects with EoE and achieving mucosal normalization.

[0141] This study was a double-blind, randomized, placebo-controlled clinical trial to examine APT - 1011 in subj ects with EoE. All subj ects had at least 4 dysphagia days during a 18-day window at baseline. The subjects received one daily dose of 3 mg APT- 1011 or placebo at bedtime for 24 weeks (FIG. 2). The primary endpoints include complete symptomatic response and histological response.

[0142] TABLE 9 shows the peak mast cell counts per HPF at a group level (APT- 1011 treatment group vs placebo group) at baseline and week 24 post treatment, respectively. The mean peak mast cell counts per HPF for the APT- 1011 treatment group at week 24 is the mean of subjects in remission (< 6 mast cell per HPF) and not in remission (> 6 mast cell per HPF).

[0143] TABLE 10 shows mucosal normalization results at week 24.TABLE 10. is of Normalization of Mucosa at Week 24: Stratified CMH

[0144] A reduction in the mast cell count is expected to correlate with mucosal normalization following treatment with a daily dose of 3 mg APT-1011 administered over a period of 24 weeks. Moreover, a reduction in the mast cell count is expected to correlate with a decreased number of dysphagia episodes following treatment. It is also anticipated that the peak post-treatment mast cell count of no more than 6 mast cells per HPF will correlate with mucosal normalization. It is further anticipated that the peak post-treatment mast cell count of no more than 6 mast cells per HPF will correlate with complete symptomatic response (e.g., zero dysphagia days over 18 consecutive days).EXAMPLE 5. A Post-hoc Analysis of 12-week and 24-week Cohorts

[0145] This study compared the Endoscopic Reference Score (EREFS) of the 12-week cohorts as described in Example 3 and 24-week cohorts as described in Example 4.

[0146] TABLE 11 shows the number and percentage of EoE Endoscopic Reference (EREF) responders at week 12 in the 12-week clinical study and at week 24 in 24-week clinical study, respectively.

[0147] TABLE 12 shows the number and percentage of EREF total score responders at week 12 in the 12- week clinical study and at week 24 in 24-week clinical study, respectively.

[0148] TABLE 13 shows the number and percentage of EREF inflammatory score responders at week 12 in the 12- week clinical study and at week 24 in 24-week clinical study, respectively.

[0149] A reduction in the mast cell count is expected to correlate with reduced endoscopic abnormalities (e.g., reduced EREFS, reduced EREF total score, and reduced EREF inflammatory score) following treatment with a daily dose of 3 mg APT- 1011 administered over a period of 12 or 24 weeks. It is also anticipated that the peak post-treatment mast cell count of no more than 6 mast cells per HPF will correlate with EREFS responder, EREF total score responder, and EREF inflammatory score responder.

Claims

CLAIMS1. A method of reducing mast cell count and / or activity in a subject in need thereof, comprising topically administering a corticosteroid to the subject’s esophageal tissue, wherein after administering the corticosteroid, the subject has a peak post-treatment mast cell count of no more than 6 mast cells per high power field (HPF) in at least one biopsy of the esophagus.

2. The method of claim 1 , further comprising obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count before topically administering the corticosteroid to the subject’s esophageal tissue.

3. The method of claim 1 or 2, further comprising obtaining at least one biopsy of the subject’s esophagus and measuring the subject’s mast cell count after topically administering the corticosteroid to the subject’s esophageal tissue for a period of time.

4. A method of treating eosinophilic esophagitis (EoE) in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 12 weeks, wherein the subject has a peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus.

5. A method of treating EoE in a subject in need thereof comprising orally administering to the subject about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, once daily for at least 24 weeks, wherein the treatment leads to a reduction in a peak post-treatment mast cell count per HPF in at least one biopsy of the esophagus of the subject by at least about 60% at week 24 compared to baseline.

6. The method of any one of claims 1-5, wherein the mast cell count is measured in the distal portion of the esophagus, the proximal portion of the esophagus, or both.

7. The method of claim 6, wherein the peak post-treatment mast cell count in the distal portion of the esophagus is no more than 6 mast cells per HPF in at least one biopsy.

8. The method of claim 7, wherein the peak post-treatment mast cell count in the proximal portion of the esophagus is no more than 6 mast cells per HPF in at least one biopsy.

9. The method of any one of claims 1-8, wherein the subject has a peak pretreatment mast cell count of 10 or more mast cells per HPF in at least one biopsy of the esophagus.

10. The method of any one of claims 1-8, wherein the subject has a peak pretreatment mast cell count of 15 or more mast cells per HPF in at least one biopsy of the esophagus.

11. The method of any one of claims 1-10, wherein the subject has a peak posttreatment mast cell count of no more than 5 mast cells per HPF in at least one biopsy of the esophagus.

12. The method of any one of claims 1-10, wherein the subject has a peak posttreatment mast cell count of no more than 4 mast cells per HPF in at least one biopsy of the esophagus.

13. The method of any one of claims 1-10, wherein the subject has a peak posttreatment mast cell count of no more than 3 mast cells per HPF in at least one biopsy of the esophagus.

14. The method of any one of claims 1-10, wherein the subject has a peak posttreatment mast cell count of no more than 2 mast cells per HPF in at least one biopsy of the esophagus.

15. The method of any one of claims 1-10, wherein the subject has a peak posttreatment mast cell count of no more than 1 mast cells per HPF in at least one biopsy of the esophagus.

16. The method of claims 1-15, wherein the method leads to a reduction in peak posttreatment mast cell count by at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 98% relative to baseline.

17. The method of any one of claims 1-16, wherein the method leads to mucosal normalization.

18. The method of any one of claims 1-17, wherein the method leads to absence of one or more of eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, or fibrosis.

19. The method claim 18, wherein the method leads to absence of eosinophilic microabscesses, degranulation, spongiosis, basal zone hyperplasia, and fibrosis.

20. The method of any of the preceding claims, wherein the subject shows an improvement in at least one of the following outcomes:(i) at least one symptom score measured using a patient reported outcome symptom evaluation (PROSE) instrument;(ii) EoE Endoscopic Reference (EREF) score;(iii) EoE Activity Index (EEsAI) avoidance, modification, and slow swallowing (AMS) score;(iv) Global EoE score;(v) Patient global impression of severity (PGIS); and(vi) Patient global impression of change (PGIC).

21. The method of any of the preceding claims, wherein 1.5 mg or 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, is administered.

22. The method of any of the preceding claims, wherein 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, is administered.

23. The method of any of the preceding claims, wherein fluticasone propionate or the corticosteroid is administered at bedtime or at nighttime.

24. The method of any of the preceding claims, wherein fluticasone propionate or the corticosteroid is administered while the subject is lying down or immediately prior to the subject lying down.

25. The method of any of the preceding claims, wherein the corticosteroid is administered once daily.

26. The method of claim 20, wherein the symptom score measured using PROSE comprises:(i) on a scale ranging from 0 to 10, a difficulty getting food down;(ii) on a scale ranging from 0 to 10, a worst discomfort with food;(iii) on a scale ranging from 0 to 10, a worst pain with food;(iv) a mean score of any combination of (i), (ii), and (iii);(v) a number of dysphagia episodes;(vi) a daily rate of dysphagia episodes; or(vii) a number of dysphagia-free days.

27. The method of claim 26, wherein the mean score is the mean of (i), (ii), and (iii).

28. The method of claim 26, wherein the mean score is the mean of (i), (ii), and (iii) calculated from one or more episodes of dysphagia over a period of time.

29. The method of claim 26, wherein if the subject experiences more than one episode of dysphagia, the mean score is calculated for the worst episode or worst symptoms of dysphagia.

30. The method of claim 26, wherein the symptom score is:(a) a daily mean of (i), (ii), and (iii) over a 14 day period;(b) a mean score of (i), (ii), and (iii) for the worst episode per day of dysphagia over a 14 day period;(c) a score for the worst symptom of dysphagia over a 14 day period;(d) a number of dysphagia episodes;(e) a daily rate of dysphagia episodes; or(f) a number of dysphagia-free days.

31. The method of any of claims 26-30, wherein at least one symptom score is improved by 0.5 to 4 points.

32. The method of any of the preceding claims, wherein the symptom score, the mean score, the worst episode score, or the worst symptom score is determined using data from 2 weeks of entries immediately prior to Week 12 and Week 26.

33. The method of any of claims 20-32, wherein the EREF score is improved by about 0.3 to 1.5 points.

34. The method of claim 33, wherein the subject is a EREF responder after treatment.

35. The method of claim 33, wherein the subject is a EREF total score responder after treatment.

36. The method of claim 33, wherein the subject is a EREF inflammatory score responder after treatment.

37. The method of any of claims 20-36, wherein the Global EoE score is improved by about 1 to 4 points.

38. The method of any of claims 20-36, wherein the PGIS score shifts to improvement by about 1 to 5 severity categories.

39. The method of any of claims 20-36, wherein the EEsAI score is improved by about 2 to 15 points.

40. The method of any of claims 20-36, wherein the subject further shows improvement in Eosinophilic Esophagitis Quality of Life Questionnaire (EoO-QoL-A).

41. The method of claim 40, wherein the EoO-QoL-A score is improved by about 1 to 3 points.

42. The method of any of the preceding claims, wherein eosinophil count in the subject’s esophagus are reduced compared to the subject’s baseline eosinophil levels as measured in at least one biopsy of the esophagus.

43. The method of claim 42, wherein the eosinophil count are reduced to no more than 6 eosinophils per high power field (HPF) in at least one biopsy of the esophagus.

44. The method of claim 43, wherein the eosinophil count are measured in the distal portion of the esophagus, the proximal portion of the esophagus, or both.

45. The method of claim 44, wherein eosinophil count in the distal portion of the esophagus is no more than 6 eosinophils per HPF in at least one biopsy.

46. The method of claim 45, wherein eosinophil count in the proximal portion of the esophagus is no more than 6 eosinophils per HPF in at least one biopsy.

47. The method of any one of claims 30-46, wherein (a) and (b) are measured at week 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and / or 12.

48. The method of claim 47, wherein (a) and (b) are measured again at week 24 and / or week 52.

49. The method of any of the preceding claims, wherein fluticasone propionate or the corticosteroid is administered for about 12 weeks to at least one year.

50. The method of any of the preceding claims, wherein the corticosteroid is formulated as a solid composition.

51. The method of claim 50, wherein the solid composition is in the form of a gel, lozenge, lollipop, effervescent tablet, powder, granules, an orally disintegrating composition or an orally dispersing composition.

52. The method of claim 51, wherein the orally disintegrating composition is a tablet, wafer, film, effervescent, or lyophilized matrix.

53. The method of claim 51, wherein the orally disintegrating composition is a tablet or effervescent.

54. The method of any one of the preceding claims, wherein the reduction in the mast cell count correlates with the reduction in the eosinophil count in at least one biopsy of the esophagus.

55. The method of claim 54, wherein there is an agreement between the peak posttreatment mast cell count of no more than 6 mast cells per HPF and the peak post-treatment eosinophil count of no more than 6 eosinophils per HPF, wherein the agreement is at least about 80%, about 85%, about 90%, or about 95%.

56. The method of claim 55, wherein the agreement is at least about 85%.

57. The method of any one of the preceding claims, wherein the reduction in the posttreatment mast cell count correlates with mucosal healing in at least one biopsy of the esophagus.

58. The method of claim 57, wherein there is an agreement between the peak posttreatment mast cell count of no more than 6 mast cells per HPF and mucosal normalization, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.

59. The method of claim 58, wherein the agreement is at least about 70%.

60. The method of any one of claims 1-59, wherein the method leads to a reduction in episodes of dysphagia.

61. The method of any one of claims 1-59, wherein, after administering the corticosteroid, the subject experiences no episodes of dysphagia over a 14 day period.

62. The method of any one of claims 1-59, wherein, after administering the corticosteroid, the subject experiences no dysphagia days over a 18 day period.

63. A method of optimizing therapy in a subject having eosinophilic esophagitis (EoE) and receiving treatment of a corticosteroid comprising(a) topically administering about 0.5 mg to about 5 mg of fluticasone propionate, or an equipotent dose of a corticosteroid, to the subject’s esophageal tissue once daily for a treatment period;(b) determining at several points in time a level of at least one mast cell-associated biomarker present in a sample from the subject, wherein the sample is selected from the group consisting of a biopsy of the esophagus, a serum sample, a blood sample, and a urine sample, wherein the biomarker is indicative of the severity of EoE in the subject; and(c) adjusting the treatment period based on the level of the at least one mast cell associated biomarker.

64. The method of claim 63, wherein the treatment comprises daily administration of 3.0 mg of fluticasone propionate, or an equipotent dose of a corticosteroid for about 12 weeks to at least one year.

65. The method of claims 63 or 64, wherein the level of the biomarker present in the sample is determined prior to the treatment and one or more times after the treatment.

66. The method of claim 65, wherein the level of the biomarker present in the sample is determined about every 4 weeks or about every 12 weeks post the treatment.

67. The method of any one of claims 63-66, wherein a reduction in the post-treatment mast cell count correlates with a reduction in the post-treatment eosinophil count in at least one biopsy of the esophagus over the treatment period.

68. The method of claim 67, wherein there is an agreement between the peak posttreatment mast cell count of no more than 6 mast cells per HPF and the post-treatment eosinophil count of no more than 6 eosinophils per HPF, wherein the agreement is at least about 80%, about 85%, about 90%, or about 95%.

69. The method of claim 68, wherein the agreement is at least about 85%.

70. The method of any one of claims 63-69, wherein a reduction in the peak posttreatment mast cell count correlates with mucosal healing in at least one biopsy of the esophagus over the treatment period.

71. The method of claim 70, wherein there is an agreement between the peak posttreatment mast cell count of no more than 6 mast cells per HPF and mucosal normalization, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.

72. The method of claims 71, wherein the agreement is at least about 70%.

73. The method of any one of claims 63-72, wherein a reduction in the mast cell count correlates with an improved symptom score of EoE.

74. The method of claim 73, wherein the symptom score comprises:(i) at least one symptom score measured using a patient reported outcome symptom evaluation (PROSE) instrument;(ii) EoE Endoscopic Reference (EREF) score;(iii) EoE Activity Index (EEsAI) avoidance, modification, and slow swallowing (AMS) score;(iv) Global EoE score;(v) Patient global impression of severity (PGIS); and(vi) Patient global impression of change (PGIC).

75. The method of claim 74, wherein the symptom score using PROSE comprises:(i) on a scale ranging from 0 to 10, a difficulty getting food down;(ii) on a scale ranging from 0 to 10, a worst discomfort with food;(iii) on a scale ranging from 0 to 10, a worst pain with food;(iv) a mean score of any combination of (i), (ii), and (iii);(v) a number of dysphagia episodes;(vi) a daily rate of dysphagia episodes; or(vii) a number of dysphagia-free days.

76. The method of claim 75, wherein the mean score is the mean of (i), (ii), and (iii).

77. The method of claim 75, wherein the mean score is the mean of (i), (ii), and (iii) calculated from one or more episodes of dysphagia over a period of time.

78. The method of claim 75, wherein if the subject experiences more than one episode of dysphagia, the mean score is calculated for the worst episode or worst symptoms of dysphagia.

79. The method of claim 75, wherein the symptom score is:(a) a daily mean of (i), (ii), and (iii) over a 14 day period;(b) a mean score of (i), (ii), and (iii) for the worst episode per day of dysphagia over a 14 day period;(c) a score for the worst symptom of dysphagia over a 14 day period;(d) a number of dysphagia episodes;(e) a daily rate of dysphagia episodes; or(f) a number of dysphagia-free days.

80. The method of any of claims 75-79, wherein at least one symptom score is improved by 0.5 to 4 points.

81. The method of any of claims 75-80, wherein the symptom score, the mean score, the worst episode score, or the worst symptom score is determined using data from 2 weeks of entries immediately prior to Week 12 and Week 24.

82. The method of any of claims 74-81, wherein the EREF score is improved by about 0.3 to 1.5 points.

83. The method of any of claims 74-81, wherein the Global EoE score is improved by about 1 to 4 points.

84. The method of any of claims 74-81, wherein the PGIS score shifts to improvement by about 1 to 5 severity categories.

85. The method of any of claims 74-81, wherein the EEsAI score is improved by about 2 to 15 points.

86. The method of any of claims 74-81, wherein the subject further shows improvement in Eosinophilic Esophagitis Quality of Life Questionnaire (EoO-QoL-A).

87. The method of claim 86, wherein the EoO-QoL-A score is improved by about 1 to3 points.

88. The method of any one of claims 63-87, wherein there is an agreement between the peak post-treatment mast cell count of no more than 6 mast cells per HPF in at least one biopsy of the esophagus and an improved symptom score, wherein the agreement is at least about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, or about 95%.

89. The method of any one of claims 63-88, wherein adjusting the treatment period based on the level of the at least one mast cell associated biomarker comprises discontinuing the administration if the peak mast cell count in at least one biopsy of the esophagus is no more than 6 mast cells per HPF.

90. A method of achieving an EREF responder, comprising topically administering a corticosteroid to a subject’s esophageal tissue, wherein the EREF responder is defined as total score between 0 and 2, inclusive, with no score for any component (edema, exudates, furrows, rings, and strictures) greater than 1 and no worsening from baseline in any component.

91. A method of achieving zero episodes of dysphagia over 14 consecutive days in a subject, comprising topically administering a corticosteroid to the subject’s esophageal tissue.

92. The method of claim 90, wherein the subject has EoE.

93. The method of any one of claims 90-92, the method further comprising the method of any one of claims 1-89.1

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