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Although an increasing number of treatment modalities have been developed, most are assessed by symptoms and the histologic metric of peak eosinophil count (\n                      <jats:styled-content style=\"fixed-case\">PEC<\/jats:styled-content>\n                      ).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>\n                      To review current evidence regarding limitations of reliance on\n                      <jats:styled-content style=\"fixed-case\">PEC<\/jats:styled-content>\n                      as a co\u2010primary endpoint while making a case for endoscopic assessment as a \u201ctrial\u2010ready\u201d outcome to supplement or replace it.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Directed literature review, including a summary of\n                      <jats:styled-content style=\"fixed-case\">EoE<\/jats:styled-content>\n                      clinical trials and outcome metrics, combined with expert discussion, input, and consensus on reviewed topics.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Clinical trials in\n                      <jats:styled-content style=\"fixed-case\">EoE<\/jats:styled-content>\n                      established efficacy based on co\u2010primary endpoints of clinically meaningful symptom improvement and\n                      <jats:styled-content style=\"fixed-case\">PEC<\/jats:styled-content>\n                      as an objective biomarker of activity. However, endoscopic features of\n                      <jats:styled-content style=\"fixed-case\">EoE<\/jats:styled-content>\n                      have a critical role in determining disease activity. The Hirano\n                      <jats:styled-content style=\"fixed-case\">EoE<\/jats:styled-content>\n                      Endoscopic Reference Score (\n                      <jats:styled-content style=\"fixed-case\">EREFS<\/jats:styled-content>\n                      ) is a uniform nomenclature system that classifies five key oesophageal findings.\n                      <jats:styled-content style=\"fixed-case\">EREFS<\/jats:styled-content>\n                      has been validated, shown to be highly accurate and responsive, and incorporated into clinical trials. An association between\n                      <jats:styled-content style=\"fixed-case\">EREFS<\/jats:styled-content>\n                      and clinically meaningful disease outcomes and complications has been demonstrated, heightening its relevance to clinical care and as a clinical trial endpoint. Defined thresholds for response of\n                      <jats:styled-content style=\"fixed-case\">EREFS<\/jats:styled-content>\n                      to therapy have been shown to be responsive to therapy.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      <jats:styled-content style=\"fixed-case\">PEC<\/jats:styled-content>\n                      has a role in histologic response assessment and should not be completely discounted. Evidence demonstrates that\n                      <jats:styled-content style=\"fixed-case\">EREFS<\/jats:styled-content>\n                      accurately reflects\n                      <jats:styled-content style=\"fixed-case\">EoE<\/jats:styled-content>\n                      disease activity and global oesophageal severity, and is ready to be used as a co\u2010primary biologic endpoint in clinical trials.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/apt.70474","type":"journal-article","created":{"date-parts":[[2025,11,26]],"date-time":"2025-11-26T05:58:40Z","timestamp":1764136720000},"page":"341-351","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Review article: Seeing Is Believing\u2013The Eosinophilic Oesophagitis Endoscopic Reference Score Can Serve as a Valuable Clinical Trial Endpoint in Eosinophilic Oesophagitis"],"prefix":"10.1111","volume":"63","author":[{"given":"Ikuo","family":"Hirano","sequence":"first","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Kenneth Griffin Oesophageal Center Northwestern University Feinberg School of Medicine  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Glenn T.","family":"Furuta","sequence":"additional","affiliation":[{"name":"Section of Pediatric Gastroenterology, Hepatology and Nutrition Children's Hospital Colorado and University of Colorado School of Medicine  Aurora Colorado USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gary W.","family":"Falk","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Perelman School of Medicine University of Pennsylvania  Philadelphia Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4698-9948","authenticated-orcid":false,"given":"Christopher","family":"Ma","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine and Department of Community Health Sciences University of Calgary, Cumming School of Medicine  Calgary Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0722-6099","authenticated-orcid":false,"given":"Nirmala","family":"Gonsalve","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Kenneth Griffin Oesophageal Center Northwestern University Feinberg School of Medicine  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1167-1101","authenticated-orcid":false,"given":"Evan S.","family":"Dellon","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Center for Oesophageal Diseases and Swallowing University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,11,25]]},"reference":[{"key":"e_1_2_16_2_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2018.07.009"},{"key":"e_1_2_16_3_1","doi-asserted-by":"publisher","DOI":"10.14309\/ajg.0000000000003194"},{"key":"e_1_2_16_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF01296781"},{"issue":"33","key":"e_1_2_16_5_1","first-page":"1419","article-title":"Idiopathic Eosinophilic Esophagitis: A Frequently Overlooked Disease With Typical Clinical Aspects and Discrete Endoscopic Findings","volume":"124","author":"Straumann A.","year":"1994","journal-title":"Schweizerische Medizinische Wochenschrift"},{"key":"e_1_2_16_6_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2017.06.067"},{"key":"e_1_2_16_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2024.09.031"},{"key":"e_1_2_16_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.gie.2022.05.013"},{"key":"e_1_2_16_9_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2019.03.025"},{"key":"e_1_2_16_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2021.04.022"},{"key":"e_1_2_16_11_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2205982"},{"key":"e_1_2_16_12_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2312282"},{"key":"e_1_2_16_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/apt.17845"},{"key":"e_1_2_16_14_1","unstructured":"FDAandCenter for Drug Evaluation and Research \u201cEosinophilic Esophagitis: Developing Drugs for Treatment Guidance for Industry \u201d(docket # 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