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 it has been shown to be effective in inducing histological and clinical remission in patients with EoE. This recommendation is based on the most recent and highest quality study, which reported a significant difference in clinicopathological response rates in patients with EoE prescribed high-dose PPI, with a response rate of 50.8% compared to 35.8% in those given standard or low-dose regimes 1.

Key Considerations

• PPI therapy should be given for at least 8-12 weeks prior to assessment of histological response while on treatment, as treatment duration of 8-10 weeks conferred a response rate of 50.4%, and longer treatment duration (>10-12 weeks) was associated with a greater rate of response (65.2%) 1.
• The use of PPI therapy in EoE is not licensed, but its use in certain situations has been shown to be effective, and patients and their general practitioners should be made aware of the reasons for the prescription of PPI, which is for the management of EoE, rather than as a GORD treatment 1.
• A systematic review and meta-analysis of 33 studies reported partial clinical and histological response rates of 60.8% and 50.5%, respectively, with PPI treatment, and a recent cross-sectional study reported histological response in 48.8% and clinical response in 71.0% of patients 1.

Treatment Approach

• PPI therapy, specifically omeprazole 20 mg twice daily, should be used as first-line therapy for 8-12 weeks, as it can reduce esophageal inflammation in approximately 30-50% of patients.
• If PPIs are ineffective, topical steroids like fluticasone or budesonide oral suspension for 8-12 weeks are recommended.
• Dietary approaches, such as the six-food elimination diet or targeted elimination based on allergy testing, may also be considered.
• Patients should be advised to avoid eating for 30-60 minutes after taking topical steroids and to rinse their mouth afterward to prevent oral candidiasis.
• Follow-up endoscopy with biopsies is typically performed after the initial treatment period to assess response.

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 EoE patients 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 in the future 3.