What is the management approach for Eosinophilic (EOS) esophagitis?

From the Guidelines

The management of Eosinophilic Esophagitis (EoE) involves a step-up approach to dietary management, starting with a 2-food exclusion diet for at least 8-12 weeks, followed by reintroduction of one food at a time to establish trigger foods, as recommended by the British Society of Gastroenterology and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition 1.

Key Considerations

• The six-food elimination diet results in higher histological remission rates than two or four food elimination diets, but is associated with lower compliance and an increased number of endoscopies 1.
• Support from an experienced dietitian is strongly recommended throughout the elimination and reintroduction process to mitigate the risks of nutritional deficiencies and ensure success on the diet 1.
• Topical corticosteroids, such as budesonide viscous suspension or fluticasone, may be considered for non-responders to dietary therapy, as recommended by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters 1.

Treatment Approach

• First-line treatment typically includes proton pump inhibitors (PPIs) such as omeprazole 20-40mg twice daily or lansoprazole 30mg twice daily for 8-12 weeks, as approximately 30-50% of patients respond to PPI therapy alone.
• For patients with severe strictures causing dysphagia, endoscopic dilation may be necessary.
• Maintenance therapy is often required as EoE is a chronic condition, with lower doses of the same medications used for initial control.

Important Considerations

• The goal of treatment is to reduce esophageal eosinophilia (less than 15 eosinophils per high-power field), improve symptoms, and prevent complications such as esophageal strictures and food impactions.
• Biologic therapies like dupilumab have recently been approved for adults and adolescents with EoE who have inadequate response to conventional treatments.
• Patients with EoE require close and structured follow-up with symptomatic, endoscopic, and histologic assessment to monitor response to treatment and prevent complications.

From the Research

Management Approach for Eosinophilic Esophagitis

The management approach for eosinophilic esophagitis (EoE) involves a combination of dietary modifications, pharmacologic therapy, and endoscopic procedures.

• 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 2.
• Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy, with effective pharmacologic therapies including corticosteroids, biological therapies, and proton pump inhibitor medications 2.

Dietary Modifications

Dietary modifications are a crucial part of EoE management, with empiric elimination diets being a commonly used approach.

• A step-up empiric elimination diet, starting with a 2-food-group elimination diet (milk and gluten-containing cereals) and progressing to a 4-food-group and 6-food-group elimination diet, has been shown to be effective in achieving EoE remission 3.
• The most common food triggers for EoE are cow's milk, wheat, and egg, with legumes being important in some geographical settings 4, 5.
• A cow's milk elimination diet has been shown to be effective in achieving remission in some patients, with retrospective efficacy data varying from 25 to 65% 5.

Pharmacologic Therapy

Pharmacologic therapy, including corticosteroids and biological therapies, is also an important part of EoE management.

• Corticosteroids have been shown to lead to clinical symptom improvement, histological improvement, and endoscopic improvement in some patients 2.
• Biological therapies, such as biologics, have also been shown to be effective in achieving histological improvement and clinical symptom improvement in some patients 2.

Endoscopic Procedures

Endoscopic procedures, including esophageal dilation, are also used in the management of EoE.

• Endoscopic esophageal dilation is a therapeutic option for fibrotic strictures due to EoE, aiming to improve obstructive symptoms such as dysphagia and food impaction 6.
• An endoscopic reference score and an optimal biopsy protocol are used to diagnose and evaluate the therapeutic response in EoE patients 6.