What are the treatment drug options for Eosinophilic Esophagitis (EOE)?

Treatment Drug Options for Eosinophilic Esophagitis (EOE)

Proton pump inhibitors (PPIs) and topical steroids are the first-line pharmacological treatments for eosinophilic esophagitis, with PPIs recommended as initial therapy due to their favorable safety profile and efficacy. 1

First-Line Pharmacological Options

Proton Pump Inhibitors (PPIs)

• Dosing recommendation: Omeprazole 20 mg twice daily for 8-12 weeks 1
  • Twice-daily dosing is significantly more effective than once-daily dosing regardless of total daily dose 2
  • After initial response, step-down therapy can be attempted:
    • First to 40 mg once daily (81% maintain remission)
    • Then to 20 mg once daily (83% of those maintain remission) 3
• Efficacy: Induces histological and clinical remission in approximately 42-50% of patients 1, 4
• Duration: Initial treatment for 8-12 weeks, followed by maintenance therapy in responders 1
• Mechanism: Beyond acid suppression, PPIs have anti-inflammatory effects and may prevent antigen penetration through epithelial repair 1

Topical Corticosteroids

• Options: Fluticasone or budesonide
• Efficacy: High-quality evidence supports their use, with histological remission in approximately 65% of patients 1, 4
• Administration:
  • For fluticasone: Metered-dose inhaler (MDI) without spacer, sprayed into mouth and swallowed
  • For budesonide: Administered as an aqueous gel (1 mg twice daily) 5
• Important note: Patients should not eat or drink for at least 30 minutes after administration 1
• Maintenance: Long-term maintenance therapy is recommended due to high relapse rates after withdrawal 1

Second-Line and Emerging Options

Dietary Therapy

• Effectiveness: Elimination diets can achieve remission in 52-69% of patients 5
• Types:
  • Six-food elimination diet (dairy, eggs, wheat, soy, peanuts, fish/shellfish)
  • Exclusive elemental diets (reserved for refractory cases due to low compliance) 1
• Limitation: Only about 55% of initial responders maintain compliance and sustained remission at 9 months 5

Biologics

• Emerging options: Dupilumab, cendakimab, and benralizumab show promise but have limited evidence 1
• Recommendation: Currently considered for refractory cases only

Endoscopic Dilation

• For patients with fibrostenotic disease and strictures
• Most effective when combined with anti-inflammatory therapy (topical steroids) 1

Ineffective Treatments (Not Recommended)

• Immunomodulators (azathioprine, 6-mercaptopurine) 1
• Anti-TNF and anti-integrin therapies 1
• Sodium cromoglycate, montelukast, and antihistamines 1
• Leukotriene receptor antagonists (may provide symptomatic relief but do not improve histology) 1

Treatment Algorithm

1. Initial therapy: PPI (omeprazole 20 mg twice daily) for 8-12 weeks
2. Assess response: Repeat endoscopy with biopsies
3. If responsive to PPI: Continue maintenance PPI therapy with potential dose reduction
4. If non-responsive to PPI: Switch to topical steroids OR consider dietary elimination
5. For refractory disease: Consider combination therapy or referral to specialist allergist/gastroenterologist 1
6. For strictures/narrowing: Add endoscopic dilation to medical therapy 1

Important Clinical Considerations

• PPI therapy should be clearly documented as treatment for EOE rather than GERD to prevent inappropriate dose reduction in primary care 1
• Candida infection may occur in patients treated with topical corticosteroids and should be managed with topical antifungals while continuing steroid therapy 1
• Patients with strictures have better outcomes when dilation is combined with anti-inflammatory therapy 1
• EOE is the most common cause of spontaneous esophageal perforation, requiring vigilance during endoscopic procedures 1

The treatment approach should be guided by symptom severity, histological findings, and patient preference, with regular monitoring for disease activity and treatment response.