What medication is recommended for an adult with eosinophilic esophagitis (EOE)?

Recommended Medications for Eosinophilic Esophagitis

For adults with eosinophilic esophagitis, start with either topical corticosteroids (budesonide or fluticasone) or proton pump inhibitors (PPIs) twice daily as first-line pharmacologic therapy, with topical steroids having the strongest evidence for efficacy. 1

First-Line Pharmacologic Options

Topical Corticosteroids (Preferred Based on Evidence Quality)

• Topical steroids are highly effective for inducing both histological and clinical remission in EOE, with high-quality evidence supporting their use 1
• Formulations include:
  • Orodispersible budesonide tablets (approved in Europe, Canada, Australia)
  • Budesonide oral suspension
  • Swallowed fluticasone (off-label)
• Maintenance therapy is essential: Clinical and histological relapse rates are high after withdrawal, so continued treatment should be recommended after achieving remission 1
• The 2022 BSG guidelines provide moderate-quality evidence that maintenance topical steroids reduce stricture development and prevent recurrent food bolus obstruction 1

Proton Pump Inhibitors (Alternative First-Line)

• PPIs are effective for inducing histological and clinical remission with moderate-quality evidence 1
• Dosing protocol: Give twice daily for at least 8-12 weeks before assessing histological response 1
• PPIs appear effective for maintaining remission in responders 1
• Important caveat: The certainty of evidence for PPIs is lower than topical steroids, with more inconsistent results 2
• PPIs work through anti-inflammatory mechanisms independent of acid suppression 3
• Only about 50% of patients achieve remission with double-dose PPI therapy 3

Second-Line Biologic Therapy

Dupilumab (Dupixent®)

• FDA-approved monoclonal antibody targeting IL-4 and IL-13 2, 4
• Reserved for patients who are:
  • Unresponsive to conventional therapies
  • Intolerant to conventional therapies
  • Not candidates for conventional therapies 2
• Approved for patients ≥12 years with ≥40 kg body weight in Europe 2
• Expanded approval in US for patients as young as 1 year weighing ≥15 kg 4

Treatment Algorithm

1. Initial therapy: Choose topical corticosteroids OR PPIs based on:

   • Patient preference
   • Cost considerations
   • Access to medications
   • Topical steroids have stronger evidence (high vs. moderate quality)

2. Duration: Treat for 8-12 weeks before endoscopic reassessment with biopsies 1

3. If response achieved: Continue maintenance therapy indefinitely

   • Do NOT discontinue after remission—relapse rates are very high 5, 1

4. If inadequate response:

   • Switch to alternative first-line agent
   • Consider dupilumab if refractory to both topical steroids and PPIs
   • Consider dietary elimination therapy (requires dietitian support)

5. If fibrostenotic disease present: Add endoscopic dilation while continuing anti-inflammatory therapy 1

Medications NOT Recommended

The following have failed to show efficacy or have unfavorable safety profiles and should NOT be used 1:

• Immunomodulators (azathioprine, 6-mercaptopurine)
• Anti-TNF agents (infliximab)
• Anti-integrin therapies (vedolizumab)
• Sodium cromoglycate
• Montelukast
• Antihistamines (for EOE specifically—may help concomitant atopic disease)
• Systemic corticosteroids

Critical Monitoring Points

• Always perform endoscopy with biopsies while on treatment to assess response—symptoms do not reliably correlate with histological activity 1
• Take at least 6 biopsies from different esophageal sites 1
• Histological remission is defined as <15 eosinophils per high-power field 1
• If symptoms recur during treatment, repeat endoscopy with biopsies 1

Common Pitfalls to Avoid

• Do not stop maintenance therapy after achieving remission—this is the most common error leading to disease recurrence 5, 1
• Do not rely on symptoms alone to assess treatment response—endoscopic and histologic assessment is mandatory 1
• Do not use allergy testing (skin prick, IgE, patch testing) to guide dietary therapy—it is ineffective 1
• Do not combine dietary and pharmacologic therapy initially—start with monotherapy and reserve combination for treatment failures 1