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, specifically omeprazole 20 mg twice daily for 8-12 weeks in adults. 1

First-Line Treatment Algorithm

1. PPI Therapy:

   • Adults: Omeprazole 20 mg twice daily for 8-12 weeks 1
   • Children: 1 mg/kg per dose, twice daily for 8-12 weeks (maximum 40 mg twice daily) 1

2. Assessment of Response:

   • Repeat endoscopy with biopsies after 8-12 weeks of PPI therapy to assess histological response 1
   • Complete response: <5 eosinophils per high-power field (hpf)
   • Partial response: 5-14 eosinophils/hpf
   • No response: ≥15 eosinophils/hpf

3. If PPI-Responsive (approximately 42-50% of patients 2):

   • Continue PPI maintenance therapy
   • Consider step-down therapy to lowest effective dose (e.g., omeprazole 40 mg once daily, then potentially 20 mg once daily) 3

4. If Non-Responsive to PPI:

   • Proceed to second-line therapy options

Second-Line Treatment Options

If PPI therapy fails to induce remission, consider:

1. Topical Steroids:

   • Budesonide orodispersible tablet 1 mg twice daily 1
   • Swallowed fluticasone (880 mcg twice daily) 1
   • Histological remission rates of 64-100% 1

2. Dietary Therapy:

   • Six-food elimination diet (SFED): eliminates milk, wheat, egg, soy, nuts, fish/seafood 1
   • Elemental diet (amino acid-based formula) - most effective but challenging adherence 1
   • Allergy-test directed elimination diet 1

Key Clinical Considerations

• Twice-daily PPI 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
• Histological assessment is essential as symptoms may not correlate with disease activity - up to 50% of patients with active inflammation may be asymptomatic 1
• Maintenance therapy is typically required as most patients relapse after discontinuation of treatment 1
• PPI side effects to monitor: diarrhea, gastrointestinal infections, magnesium deficiency 1

Special Situations

• Food bolus obstruction: In patients presenting with food bolus impaction, EoE should be suspected and biopsies taken during the index endoscopy 1
• Esophageal strictures: Consider endoscopic dilation in addition to anti-inflammatory therapy 4
• Psychological impact: Be aware of the psychological burden of dietary therapy and chronic disease management, particularly in children 1

PPI therapy has evolved from being just a diagnostic test to exclude GERD to becoming a legitimate first-line treatment for EoE, with response rates of approximately 42-50% 2. The mechanism may involve both acid suppression and anti-inflammatory effects. For patients who don't respond to PPI therapy, topical steroids and dietary modifications offer effective alternatives with high response rates.