From the Guidelines
The treatment for eosinophilic esophagitis (EoE) should commence with a single modality therapy of either diet or pharmacotherapy, with pharmacotherapy being the preferred initial approach for most patients, as it is easier to implement than dietary restriction. This recommendation is based on 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 guidelines suggest that combining elimination diets with pharmacological treatment is not routinely recommended but can be considered in cases of treatment failure. Topical corticosteroids, such as swallowed fluticasone or budesonide oral suspension, are effective in reducing inflammation and improving symptoms in patients with EoE. Dietary therapy, including elimination diets, can also be effective in managing EoE, but it requires motivation, multiple endoscopies, and support from a specialist dietitian.
Some key points to consider in the treatment of EoE include:
- The use of proton pump inhibitors (PPIs) as a first-line therapy, although the evidence for this is conditional and of very low quality 1
- The recommendation for topical glucocorticosteroids over no treatment, with a strong recommendation and moderate quality of evidence 1
- The suggestion to use an empiric, 6-food elimination diet over no treatment, with a conditional recommendation and low quality of evidence 1
- The importance of regular follow-up endoscopies to monitor treatment response and adjust therapy as needed
It is essential to note that EoE is a chronic condition, and long-term management is typically required. Maintenance therapy often consists of lower doses of the medications that induced remission. 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.
From the Research
Treatment Options for Eosinophilic Esophagitis
- The treatment for eosinophilic esophagitis (EoE) includes several options such as elimination diets, drug therapy (oral and topical steroids), and esophageal dilatations 2.
- Proton pump inhibitors (PPI) are often used as first-line treatments, with a histologic response rate of 41.7% compared to 13.3% for placebo 3.
- Topical steroid preparations, such as fluticasone and budesonide, have been shown to be effective in achieving histologic remission in 64.9% of patients compared to 13.3% for placebo 3.
- Dietary therapy with amino acid formula or empirical food elimination is also a treatment option, with an initial response rate of over 50% possible with the elimination diet plus PPI 4.
- Endoscopic esophageal dilation is a therapeutic option for fibrotic strictures due to EoE to improve obstructive symptoms, such as dysphagia and food impaction 5.
Emerging Therapies
- Novel therapies, including esophageal-targeted formulas of topic corticosteroids and monoclonal antibodies, are being investigated for the treatment of EoE 6.
- Monoclonal antibodies, such as mepolizumab, reslizumab, and dupilumab, have shown efficacy and safety in short-term studies 6.
- Personalized therapeutic strategies for initial and maintenance treatments of EoE are being developed to reduce the burden of disease and address the needs of patients 6.
Treatment Outcomes
- Remission was sustained in over 85% of patients at 3 months with all treatment modalities, including PPI, elimination diet, and budesonide 4.
- However, long-term sustainability of remission is a concern, with only 55% of patients who responded to the elimination diet with PPI remaining in remission at 9 months 4.
- Budesonide has been shown to be very effective in the short term, but longer-term studies are needed to assess its sustainability 4.