From the Guidelines
The treatment of eosinophilic esophagitis (EoE) should start with proton pump inhibitors (PPIs) such as omeprazole 20mg twice daily for 8-12 weeks, as recommended by the British Society of Gastroenterology and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition 1.
Treatment Approaches
The treatment of EoE involves three main approaches:
- Dietary therapy
- Medications
- Endoscopic dilation First-line medication therapy typically includes PPIs, with omeprazole being the only PPI that has been assessed for the treatment of EoE 1.
Medication Therapy
If PPIs are ineffective, topical corticosteroids are recommended, with budesonide or fluticasone being commonly used options 1.
- Budesonide: 1mg twice daily as an oral viscous suspension
- Fluticasone: 440-880mcg twice daily (sprayed and swallowed, not inhaled)
Dietary Therapy
Dietary therapy involves elimination diets, starting with removing the six most common allergens (milk, wheat, eggs, soy, nuts, and seafood) for 6-8 weeks, then reintroducing foods systematically to identify triggers 1.
Endoscopic Dilation
For patients with severe strictures causing dysphagia, endoscopic dilation may be necessary to mechanically expand the esophagus, and should be offered along with other forms of disease modification using diet, topical steroids or other drugs 1.
Maintenance Therapy
Maintenance therapy is often required as EoE is chronic, with lower doses of the effective initial treatment, and treatment selection should be individualized based on patient preferences, symptom severity, and response to therapy, with regular follow-up to assess effectiveness and adjust treatment as needed 1.
From the FDA Drug Label
Treatment of EE due to Acid-Mediated GERD 20 mg once daily 4 to 8 weeks The efficacy of omeprazole used for longer than 8 weeks in patients with EE has not been established. If a patient does not respond to 8 weeks of treatment, an additional 4 weeks of treatment may be given. If there is recurrence of EE or GERD symptoms (e.g., heartburn), additional 4 to 8 week courses of omeprazole may be considered.
The treatment for eosinophilic esophagitis is not directly addressed in the provided drug labels. However, the labels do provide information on the treatment of EE due to Acid-Mediated GERD.
- The recommended dosage for EE due to Acid-Mediated GERD is 20 mg once daily for 4 to 8 weeks 2.
- If a patient does not respond to 8 weeks of treatment, an additional 4 weeks of treatment may be given.
- If there is recurrence of EE or GERD symptoms, additional 4 to 8 week courses of omeprazole may be considered 2. However, eosinophilic esophagitis and EE due to Acid-Mediated GERD are different conditions, and the provided drug labels do not directly support the use of omeprazole for the treatment of eosinophilic esophagitis.
From the Research
Treatment Options for Eosinophilic Esophagitis
- Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission 3
- Empirical elimination diets are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers 3
- Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages 3
Pharmacologic Therapies
- Corticosteroids may lead to slightly better clinical improvement, large histological improvement, and may lead to slightly fewer withdrawals due to adverse events 4
- Biologics may result in little to no difference in clinical improvement, better histological improvement, and may result in little to no difference in endoscopic improvement 4
- Proton pump inhibitors (PPIs) are the most administered first-line treatment for eosinophilic esophagitis (EoE), but only around half of EoE patients respond histologically to a double dosage of PPI 5
Dietary Therapy
- Dietary therapy with amino acid formula or empirical food elimination is a current therapy for EoE 6
- Exclusive elemental diets and suboptimal allergy testing-directed food avoidance have been replaced by empirical elimination diets 3
Endoscopic Dilation
- Endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission 3
- Esophageal dilation is reserved for patients with symptomatic esophageal narrowing 6
Treatment Goals
- The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications 4