What is the initial treatment for Eosinophilic Esophagitis (EoE)?

From the Guidelines

The initial treatment for Eosinophilic Esophagitis (EoE) should be proton pump inhibitor (PPI) therapy, specifically omeprazole 20 mg twice daily, for at least 8-12 weeks, as recommended by the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines 1.

Key Considerations

• PPI therapy has been shown to be effective in inducing histological and clinical remission in patients with EoE, with a clinicopathological response rate of 50.8% reported in patients prescribed high-dose PPI, such as omeprazole 20 mg twice daily 1.
• The use of PPI therapy in EoE is not licensed, but its effectiveness has been demonstrated in various studies, including a systematic review and meta-analysis of 33 studies, which reported partial clinical and histological response rates of 60.8% and 50.5%, respectively 1.
• Treatment duration is also an important factor, with longer treatment duration (>10-12 weeks) associated with a greater rate of response (65.2%), although the effect may diminish in patients treated longer than this 1.

Treatment Approach

• PPI therapy should be given for at least 8-12 weeks prior to assessment of histological response while on treatment, with a minimum dose of omeprazole 40 mg daily or equivalent 1.
• If PPIs are ineffective, other treatment options, such as swallowed topical corticosteroids or dietary modifications, may be considered.
• Treatment success should be evaluated through symptom improvement and follow-up endoscopy with biopsies to confirm reduction in eosinophil count.

Important Notes

• The GDG recommends that if using PPI therapy to manage EoE, omeprazole at a dose of 20 mg twice daily should be used, with a clear explanation of its indication in correspondence with the primary care team 1.
• Long-term management often requires maintenance therapy, as EoE is typically a chronic condition that can recur when treatment is discontinued 1.

From the Research

Initial Treatment for Eosinophilic Esophagitis (EoE)

The initial treatment for Eosinophilic Esophagitis (EoE) typically involves a combination of medical therapies and dietary changes.

• The first line of treatment often includes proton pump inhibitors (PPIs) and/or topical corticosteroids, such as fluticasone and budesonide 2, 3, 4.
• Elimination diets, where common food triggers are removed, may also be recommended as an initial treatment approach 2, 4.
• Topical corticosteroids, such as swallowed fluticasone propionate, have been shown to be effective in inducing histologic remission in both pediatric and adult patients with EoE 5, 6.

Treatment Outcomes

• Studies have demonstrated that PPI therapy can lead to histologic response in approximately 41.7% of patients, while topical corticosteroid treatment can achieve histologic remission in around 64.9% of patients 4.
• The effectiveness of these treatments can vary depending on individual patient factors, such as the presence of allergies or the severity of symptoms 5.
• Regular follow-up and monitoring are essential to assess treatment response and make adjustments as needed 2, 3.

Additional Considerations

• Esophageal dilation may be necessary for patients with symptomatic esophageal narrowing 4.
• New formulations of topical corticosteroids and investigational therapies targeting specific molecular pathways are being developed and may offer additional treatment options for EoE in the future 3.