What are the treatment options for recurrent Eosinophilic Esophagitis (EoE)?

Treatment Options for Recurrent Eosinophilic Esophagitis (EoE)

For recurrent eosinophilic esophagitis, the most effective treatment approach involves either topical corticosteroids or dietary elimination therapy, with the choice depending on patient factors such as age, symptom severity, and presence of esophageal structural abnormalities. 1

First-Line Treatment Options

Pharmacological Therapy

• Swallowed topical corticosteroids (first choice for most patients)
  • Easier to implement than dietary restrictions
  • Effective for both symptom improvement and histological resolution
  • High histological improvement rate (63% higher than placebo) 2
  • Options include fluticasone and budesonide
  • Potential side effect: esophageal candidiasis

Dietary Therapy

• Elimination diets (requires specialist dietitian support)
  • Options in order of restrictiveness:
    1. Six-food elimination diet (SFED): eliminates milk, wheat, egg, soy, nuts, and fish/seafood
    2. Four-food elimination diet: eliminates dairy, wheat/gluten, egg, and legumes
    3. Two-food elimination diet: eliminates dairy and wheat/gluten
    4. Single food elimination: typically starts with milk (most common trigger)
  • A step-up approach (2-4-6) may be practical to minimize restrictions 3
  • Elemental diet: highly effective but poor adherence; reserved for treatment-refractory cases 1

Important Considerations

• Allergy testing is NOT recommended for guiding dietary elimination 1
  • EoE is primarily a non-IgE mediated condition
  • Allergy test-directed diets have lower histological remission rates

Treatment Algorithm for Recurrent EoE

1. Assess previous treatment response:

   • If previously responded to topical steroids → restart the same regimen
   • If previously responded to dietary therapy → reinstitute the same diet

2. For patients with inadequate response to initial therapy:

   • Switch treatment modality (from steroids to diet or vice versa)
   • Consider esophageal dilation for patients with strictures 1

3. For patients with multiple recurrences:

   • Consider maintenance therapy with lower-dose topical steroids
   • Evaluate for strictures requiring dilation
   • Monitor for complications (food impaction, esophageal tears) 1

Monitoring Response

• Regular clinic visits to assess symptoms, compliance, and adverse effects
• Repeat endoscopy with biopsy no sooner than 4 weeks after treatment initiation 1
• For asymptomatic patients with persistent eosinophilia:
  • Consider additional treatment
  • If treatment deferred, repeat endoscopy every 2-3 years to monitor for disease progression 1

Emerging Therapies for Refractory Cases

• Biologic agents targeting type 2 inflammation:
  • Anti-IL-5 antibodies (mepolizumab, reslizumab)
  • Anti-IL-13 (RPC4046)
  • Anti-IL-4/IL-13 (dupilumab)
  • Shown to improve histological outcomes (55% higher than placebo) 2, 4
  • Currently not recommended for routine use but may be considered in selected refractory cases 1, 5

Important Pitfalls to Avoid

1. Rapid recurrence after discontinuation: Studies show median time to symptom recurrence of 244 days after successful treatment 6

   • Consider maintenance therapy for patients achieving histologic response

2. Discordance between symptoms and histology: Substantial esophageal eosinophilia may persist in asymptomatic patients 1

   • Treatment decisions should consider both symptoms and histology

3. Risk of complications: Patients with EoE are at increased risk for esophageal tears and perforation 1

   • Use caution with endoscopic procedures

4. Combination therapy: Not routinely recommended but can be considered in treatment failure cases 1

   • Should only be implemented with support from a multidisciplinary team

By following this structured approach to recurrent EoE, clinicians can effectively manage symptoms, prevent complications, and improve quality of life for patients with this chronic inflammatory condition.