What is the management of Eosinophilic Esophagitis (EoE)?

From the Guidelines

The management of eosinophilic esophagitis (EoE) should primarily involve topical glucocorticosteroids as the first-line treatment, as recommended by the AGA/JTF guidelines 1. The treatment of EoE involves a multi-faceted approach, including:

• Dietary therapy: Eliminate common food triggers (milk, wheat, eggs, soy, nuts, fish/shellfish) or follow an elemental diet, with the goal of reducing eosinophilic inflammation and alleviating symptoms.
• Medications:
  • Topical corticosteroids:
    • Fluticasone: 440-880 mcg twice daily, swallowed (not inhaled)
    • Budesonide: 1 mg twice daily, mixed with sucralose to create a viscous suspension, as recommended by the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition joint consensus guidelines 1.
  • Proton pump inhibitors (PPIs): e.g., omeprazole 20-40 mg twice daily for 8-12 weeks, although the evidence for this is conditional and of very low quality 1. Patients should be re-evaluated after 8-12 weeks of initial therapy. If symptoms persist or worsen, consider:
• Endoscopic dilation: For patients with severe strictures or persistent dysphagia despite medical therapy, as recommended by the UK guidelines on oesophageal dilatation in clinical practice 1.
• Biologic therapies: For refractory cases, dupilumab (300 mg subcutaneously every 2 weeks) may be considered, although the evidence for this is not explicitly stated in the provided guidelines. Ongoing management includes:

• Regular follow-up and endoscopic monitoring
• Maintenance therapy with lower doses of medications or continued dietary restrictions
• Patient education on proper medication administration and potential complications The goal of treatment is to reduce eosinophilic inflammation, alleviate symptoms, and prevent complications like strictures. Dietary therapy works by eliminating potential allergens, while medications like topical corticosteroids reduce inflammation. Endoscopic interventions physically address structural changes in severe cases. It is essential to note that allergy testing to foods (skin prick, specific IgE, patch testing) is not recommended for choosing the type of dietary restriction therapy for eosinophilic oesophagitis, as stated in the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition joint consensus guidelines 1.

From the Research

Management of Eosinophilic Esophagitis (EoE)

The management of Eosinophilic Esophagitis (EoE) involves a multidisciplinary approach with various treatment options. The goals of treatment are to minimize esophageal inflammation, improve symptom control, and prevent progression to a more severe disease phenotype 2, 3, 4, 5, 6.

Treatment Options

• Dietary Therapy: Targets dietary allergens and includes the elemental diet, the allergy testing-directed elimination diet, and the empiric elimination diet 2, 3, 4, 6.
• Pharmacologic Options: Topical corticosteroids are the standard first-line treatment, while other pharmacologic interventions are currently under investigation and not recommended in the most recent guidelines 2, 3, 5.
• Endoscopic Dilation: Usually reserved for patients who relapse on pharmacologic or dietary regimens or who have symptomatic stricturing disease 2, 3, 4, 6.
• Proton Pump Inhibitors (PPIs): Play an important role in the diagnostic pathway of EoE and may be used as a treatment option for patients with PPI-responsive esophageal eosinophilia (PPI-REE), a subset or variant of EoE 3, 4, 5.

Approach to Management

The approach to management of EoE requires consideration of patient symptoms, phenotype (inflammatory vs fibrostenotic), and preferences 4. Maintenance anti-inflammatory therapy is necessary to prevent esophageal fibrotic remodeling and stricture formation 4. The management of EoE can be summarized as the three Ds: drugs, dietary therapy, and esophageal dilation 6.