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

Initial Treatment for Eosinophilic Esophagitis (EoE)

Proton pump inhibitor (PPI) therapy should be the initial treatment for eosinophilic esophagitis, given at a dose of omeprazole 20 mg twice daily for 8-12 weeks in adults, followed by assessment of histological response. 1

First-Line Treatment Algorithm

1. PPI Therapy (First-Line)

   • Adults: Omeprazole 20 mg twice daily for 8-12 weeks 1
   • Children: 1 mg/kg twice daily for 8-12 weeks (maximum 40 mg twice daily) 1
   • Response rates: Approximately 50% of patients achieve histological remission with twice-daily dosing 1, 2

2. Assessment of Response

   • Repeat endoscopy with biopsies after 8-12 weeks of PPI therapy 1
   • Histological remission defined as <15 eosinophils per high-power field 1
   • Clinical symptoms may not correlate with histological activity, making endoscopic assessment essential 1

3. If PPI-Responsive

   • Continue PPI maintenance therapy 1
   • Consider dose reduction to lowest effective dose (e.g., omeprazole 40 mg once daily, then potentially 20 mg once daily) 3
   • Long-term maintenance therapy is recommended due to high relapse rates (87.5%) upon discontinuation 1

4. If Not PPI-Responsive

   • Proceed to second-line therapy:
     • Topical steroids (e.g., budesonide orodispersible tablet 1 mg twice daily) 1
     • OR elimination diet (six-food elimination diet or elemental diet) 1

Evidence Quality and Considerations

The recommendation for PPI as first-line therapy is supported by strong evidence:

• Recent meta-analyses show histological response rates of approximately 50% with twice-daily PPI dosing 1
• Twice-daily dosing is significantly more effective than once-daily dosing regardless of total daily dose (52.8-54.3% vs 10-11.8% response rates) 2
• PPI therapy has been shown to maintain remission in approximately 70% of initial responders at 12 months 1

Important Clinical Pearls

• Dosing schedule matters: Twice-daily PPI dosing is significantly more effective than once-daily dosing, even at the same total daily dose 2
• Mechanism: PPIs work not only by acid suppression but may have anti-inflammatory effects in EoE 1
• Duration: Initial treatment should be at least 8-12 weeks before assessing response 1
• Monitoring: Histological assessment is essential as symptoms may not correlate with disease activity 1
• Side effects: If PPI causes unwanted side effects (diarrhea, GI infections, magnesium deficiency), consider switching to topical steroids or dietary therapy 1

Special Considerations

• Children: PPI therapy is also first-line in pediatric patients, with dosing at 1 mg/kg twice daily (maximum 40 mg twice daily) 1
• Food impaction: In patients presenting with food bolus obstruction, urgent endoscopy with biopsies should be performed, followed by PPI therapy if EoE is confirmed 1
• Psychological impact: The psychological burden of treatment, particularly with dietary therapy, should be considered when selecting treatment options 1

By following this algorithm, clinicians can effectively manage EoE with the goal of achieving both symptomatic and histological remission, thereby reducing the risk of complications such as stricture formation and food impaction.