What is the prognosis and treatment for eosinophilic esophagitis?

From the Guidelines

The prognosis for eosinophilic esophagitis (EoE) is generally good with appropriate treatment, though it is a chronic condition requiring ongoing management. Treatment typically involves a multi-modal approach combining dietary modifications, medications, and sometimes endoscopic interventions. First-line medication therapy includes proton pump inhibitors (PPIs) such as omeprazole 20-40mg twice daily or lansoprazole 30mg daily for 8-12 weeks, which reduce acid production and have anti-inflammatory effects 1. Topical corticosteroids are also highly effective, with options including fluticasone (880-1760mcg/day, sprayed and swallowed) or budesonide oral suspension (1mg twice daily for adults) 1. These medications reduce esophageal inflammation and eosinophil counts.

Key Considerations

• Dietary therapy involves either targeted elimination of specific food triggers identified through allergy testing or empiric elimination diets (commonly removing dairy, wheat, eggs, soy, nuts, and seafood) for 6-8 weeks followed by sequential reintroduction 1.
• For patients with severe strictures causing dysphagia, endoscopic dilation may be necessary to expand the esophageal lumen 1.
• Long-term management typically requires maintenance therapy as most patients relapse when treatment is discontinued.
• Biologic therapies targeting specific inflammatory pathways, such as dupilumab, are emerging options for refractory cases 1.

Treatment Goals

• Control symptoms
• Reduce inflammation
• Prevent complications like strictures
• Improve quality of life while minimizing medication side effects

Recent Guidelines

The British Society of Gastroenterology (BSG) and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults recommend a multi-modal approach to treatment, including dietary modifications, medications, and endoscopic interventions 1. The guidelines also emphasize the importance of patient education and shared decision-making in the management of EoE.

The goal of treatment is to achieve a balance between controlling symptoms, reducing inflammation, and improving quality of life, while minimizing medication side effects and preventing complications.

From the Research

Prognosis for Eosinophilic Esophagitis

• The prognosis for eosinophilic esophagitis (EoE) is generally favorable with appropriate treatment, but the disease is chronic and requires long-term management 2, 3, 4.
• Without treatment, EoE can progress to fibrostenosis, leading to complications such as esophageal strictures and food bolus impaction 2, 4.
• Long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with EoE 2.

Treatment Options for Eosinophilic Esophagitis

• Current treatment options for EoE include:
  • Dietary therapy, such as amino acid formula or empirical food elimination 3, 4
  • Pharmacological therapy, including proton pump inhibitors (PPIs) and swallowed topical corticosteroids (STSs) 2, 3, 5
  • Endoscopic dilation for patients with symptomatic esophageal narrowing 3, 4
• Dupilumab, a humanized monoclonal antibody, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE 4, 5.

Factors Affecting Prognosis and Treatment

• The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved 2, 4.
• Genetic and environmental factors, such as exposure to antibiotics early in life, are associated with EoE 3.
• Symptom alleviation is not the sole end point of treatment in EoE, as persistent inflammation can lead to esophageal fibrosis and stricture formation over time 4.