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

Initial Treatment for Eosinophilic Esophagitis (EoE)

Proton pump inhibitor (PPI) therapy should be the first-line treatment for eosinophilic esophagitis, administered twice daily for 8-12 weeks. 1

PPI Therapy Protocol

Dosing Recommendations

• Adults: Omeprazole 20 mg twice daily (or equivalent PPI) for 8-12 weeks 1
• Children: 1 mg/kg twice daily (up to 40 mg twice daily) for 8-12 weeks 1

Efficacy

• PPI therapy induces histological remission in approximately 50% of patients 1
• Twice-daily dosing is significantly more effective than once-daily dosing, regardless of total daily dose 2
• A meta-analysis showed histological response rates of 50.8% with high-dose PPI versus 35.8% with standard/low-dose regimens 1

Assessment of Response

• Repeat endoscopy with biopsies should be performed after 8-12 weeks of treatment to assess histological response 1
• Target for histological remission: <15 eosinophils per high-power field 1
• Clinical symptoms may not always correlate with histological activity, making endoscopic assessment crucial 1

Alternative First-Line Options

Topical Corticosteroids

If PPI therapy is contraindicated or patient preference dictates:

• Adults: Swallowed fluticasone 880 mcg (four puffs) twice daily or budesonide orodispersible tablet 1 mg twice daily 1
• Children: Oral viscous budesonide 1 mg/day if <150 cm or 2 mg/day if >150 cm 1
• Histological remission rates: 62-100% depending on formulation 1

Dietary Therapy

Consider as an alternative first-line approach, particularly in children or motivated adults:

• Three effective approaches:
  1. Elemental diet (amino acid-based formula) - most effective but least practical
  2. Six-food elimination diet (SFED) - eliminates milk, wheat, egg, soy, nuts, fish/seafood
  3. Targeted elimination based on allergy testing
• Histological response rates: 72.1% for SFED, 90.8% for elemental diets 1

Management Algorithm

1. Initial Diagnosis: Confirm EoE with ≥15 eosinophils/hpf on esophageal biopsy
2. First-line Treatment: Start PPI therapy (omeprazole 20 mg twice daily for adults)
3. Assessment: Repeat endoscopy with biopsies after 8-12 weeks
4. If Responsive to PPI:
   • Continue maintenance PPI therapy
   • Consider dose reduction to lowest effective dose after achieving remission
5. If Non-responsive to PPI:
   • Switch to topical corticosteroids OR
   • Implement dietary therapy OR
   • Consider combination therapy (PPI + topical steroid)

Important Considerations

• PPI Maintenance: In patients who achieve histological response, long-term PPI therapy is effective in maintaining remission in approximately 70% of patients 1
• Side Effects: If PPI causes unwanted side effects (diarrhea, GI infections, magnesium deficiency), consider switching to alternative treatments 1
• Psychological Impact: The psychological burden of dietary therapy should be discussed with patients, as it can significantly impact quality of life 1
• Food Bolus Obstruction: In patients presenting with food bolus obstruction, EoE should be suspected and biopsies taken at index endoscopy 1

Common Pitfalls to Avoid

• Inadequate PPI Trial: Using once-daily dosing or insufficient duration (<8 weeks) may lead to underestimation of PPI responsiveness 2
• Relying on Symptoms Alone: Clinical symptoms may improve without histological remission; endoscopic assessment is essential 1
• Insufficient Biopsies: At least 6 biopsies from different anatomical sites in the esophagus should be taken to diagnose EoE and assess treatment response 1
• Overlooking Maintenance Therapy: Failure to maintain therapy after initial response can lead to relapse and food bolus obstruction 1

By following this evidence-based approach to initial EoE treatment, clinicians can effectively manage this condition and improve patient outcomes in terms of morbidity, mortality, and quality of life.