From the Guidelines
The primary treatment for eosinophilic esophagitis (EoE) should be initiated with a single modality therapy of either diet or pharmacotherapy, with pharmacotherapy being easier to implement and recommended for most patients. According to the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults 1, the treatment options for EoE include:
- Dietary therapy: Eliminate common food allergens for 6-8 weeks, then reintroduce foods one at a time to identify triggers
- Topical corticosteroids:
- Fluticasone: 440-880 mcg twice daily, swallowed (not inhaled)
- Budesonide: 1 mg twice daily, mixed with artificial sweetener to create a viscous solution Use for 8-12 weeks initially, then taper to lowest effective dose for maintenance
- Proton pump inhibitors (PPIs): Omeprazole 20-40 mg once or twice daily, or equivalent, for 8-12 weeks, as recommended by the BSG and BSPGHAN joint consensus guidelines 1 Combination therapy of drugs and diet should be reserved for selected patients who fail monotherapy and have access to a multiprofessional team including a dietitian to follow them up and monitor response carefully 1. Allergy testing to foods is not recommended for choosing the type of dietary restriction therapy for eosinophilic oesophagitis, as it has been found to be no more effective than empirical dietary elimination 1. The AGA/JTF suggests using proton pump inhibition over no treatment in patients with symptomatic esophageal eosinophilia, although the strength of the recommendation was lowered due to the low-quality evidence 1. It is essential to note that the treatment of EoE should be tailored to individual patient response and preferences, and long-term management often requires a combination of these approaches.
From the FDA Drug Label
Treatment of EE due to Acid-Mediated GERD 20 mg once daily 4 to 8 weeks Maintenance of Healing of EE due to Acid-Mediated GERD 20 mg once daily 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 options for Eosinophilic Esophagitis (EE) include:
- Omeprazole 20 mg once daily for 4 to 8 weeks for treatment of EE due to acid-mediated GERD 2
- Omeprazole 20 mg once daily for maintenance of healing of EE due to acid-mediated GERD 2
- Additional 4-week courses of omeprazole may be considered if there is recurrence of EE or GERD symptoms 2
- Additional 4 to 8 week courses of omeprazole may be considered if the patient does not respond to initial 8 weeks of treatment 2
From the Research
Treatment Options for Eosinophilic Esophagitis (EE)
The treatment options for Eosinophilic Esophagitis (EE) can be categorized into several approaches, including:
- Dietary therapy: targets dietary allergens and encompasses the elemental diet, the allergy testing-directed elimination diet, and the empiric elimination diet 3
- Pharmacologic options:
- Endoscopic dilation: usually reserved for patients who relapse on pharmacologic or dietary regimens or who have symptomatic stricturing disease 3, 4, 7
Goals of Treatment
The goals of treatment for EE include:
- 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
- Prevention of disease progression and subsequent complications 6
Effectiveness of Treatment Options
The effectiveness of different treatment options for EE has been studied in various clinical trials, with results showing that:
- Corticosteroids may lead to clinical symptom improvement, histological improvement, and endoscopic improvement 6
- Biologics may lead to histological improvement, but the evidence is less clear for clinical symptom improvement and endoscopic improvement 6
- PPIs may be effective as a first-line therapy for EE, in addition to the use of topical corticosteroids 5